Have you ever been insulted by your own medical records?
Medical jargon can be confusing, and sometimes it hurts a patient's feelings. Recently on Twitter, a group of health care workers shared stories of patients who became upset after reading the physician notes in their medical records.
One patient read the notes from her colonoscopy report, which included a reference to a "time out." The woman reportedly was upset by this, and called her doctor saying she was "well behaved during the procedure and did not need a 'time out.'"
The good news is that the patient wasn't in trouble. What she didn't realize is that the "time out" noted in her medical record referred to a crucial safety step that doctors are supposed to take before medical procedures and surgeries. Members of the medical team take a "time out" immediately before starting their work to triple check that the right procedure is being performed on the right patient and on the correct body part. (While medical errors can still happen, this protocol has drastically reduced "wrong site" surgeries, in which doctors mistakenly operate on the left leg, for example, rather than the right one.)
But misunderstandings like this are becoming more common as patients gain access to their electronic medical records. Many hospital systems offer convenient portals where patients can check in for appointments, send notes to their doctor and read lab results and medical records.
A report titled, "Your Patient Is Now Reading Your Note," from researchers at the University of Washington and Harvard Medical School, advised doctors to think about supportive language when making notes in a patient's chart, and said that common medical jargon could be confusing or feel judgmental when read by patients.
For instance, medical records often describe the patient's appearance. A patient may be insulted to see themselves described as "disheveled." Instead, the report advised, be specific and say, "The patient's shirt was untucked."
Reading scary medical terms in the patient record can also be devastating to a lay person. A doctor may casually write that a patient has "renal failure." A better description is "chronic kidney disease," the report said.
The study noted that abbreviations commonly used in medicine could also be a problem, including:
◼️ SOB: The report advised doctors to write out "short of breath" to avoid offending the patient.
◼️ F/U: It's better to avoid abbreviating the words "follow up" when noting a patient's medical record.
◼️ OD: This abbreviation for the Latin term "oculus dexter," or the right eye, can cause confusion.
In the recent Twitter discussion, health workers added to the list of potentially unsettling medical terms.
◼️ "Patient is a poor historian." It's not a criticism of the patient's knowledge of history, but the way doctors often note that a patient can't remember details of their own medical history.
◼️ "Patient is well nourished." While it might sound unflattering, the term usually just means the patient isn't malnourished.
◼️ "Denies recreational drug use." A patient was upset by the phrase, because she thought that it implied she was lying about substance use.
◼️ "Dizziness and giddiness." A patient was appalled by this description, but the terms are commonly used to describe a patient who feels unbalanced or lightheaded.
◼️ "Slow k OD" A patient's wife saw this and thought it suggested a patient had overdosed. In this case, the shorthand actually meant the patient took a prescription potassium tablet once a day. (The letter "K" is the symbol for potassium on the periodic table.)