Medical records are essential tools that offer insights into your health and provide reminders about treatment recommendations.
However, they often contain complex medical terms and hard-to-pronounce illnesses that can be challenging to understand.
More importantly, the records might also include inaccuracies or unexpected language that could leave patients feeling judged or misunderstood.
Dr Robert Shmerling, the senior faculty editor at Harvard Health Publishing, says studies have found that stigmatising language in medical notes could negatively impact patients.
Such language could make individuals feel judged and affect the quality of health care they receive.
It might even discourage people from seeking care and contribute to health disparities. One study linked stigmatising language to higher rates of medical errors, particularly among black patients.
Examples of stigmatising language
Depersonalisation: Medical notes might refer to a patient as “a drug-abusing addict” instead of recognising them as a person struggling with drug addiction.
Inappropriate descriptors: Notes might include subjective descriptions that cast the patient negatively, without context. For instance, saying, “The patient is unkempt and is drug-seeking”, rather than, “The patient is experiencing homelessness and has severe, chronic pain”.
If someone has a hazy recall of past medical events, they might be labelled “unreliable”.
Dismissiveness: A note might imply that a symptom is exaggerated or not real, rather than taking the patient’s complaint seriously.
Untrusting tone: Phrases like “she claims she never drinks” or “he denies alcohol use” might suggest mistrust by the physician.
Time pressure
The rush to document patient information could lead to mistakes and the use of inappropriate language.
Bias
Doctors, like everyone else, have biases, some of which they might not be aware of. The biases could influence their language and perceptions of patients.
Frustration
Physicians might express frustration in their notes if patients did not follow medical advice.
For example, a note might read: “As expected, the patient’s blood sugar is high; he is not checking his blood sugar or following the diet recommended by his nutritionist.”
If you find confusing or bothersome language in your medical notes, it’s important to address it. This is to promote transparency and communication between patients and health-care providers.
While changing the language in medical notes is generally positive, some doctors worry that notes might become less specific or useful if information that could upset patients was omitted.
However, reading your medical notes could help improve the language used and ensure greater accuracy over time.
Shmerling encourages patients to review their health-care providers’ notes. If you notice a substantial error or something unclear or objectionable, don’t hesitate to ask about it.
Although a signed medical note cannot usually be revised, doctors could make clarifications or correct mistakes in an addendum.
Understand your health better
Your medical records contain detailed information about your health history, treatments and diagnoses. By reading them, you can gain a clearer understanding of your health status and the care you’ve received.
Catch errors early
Mistakes can happen in medical records, just like in any other field. Reviewing your records allows you to spot any inaccuracies or missing information that could affect your treatment.
Be an active participant in your care
When you understand your medical records, you become a more active participant in your health care. You can ask informed questions and have more meaningful discussions with your health-care providers.
Prepare for appointments
Having a good grasp of your medical records can help you prepare for medical appointments. You’ll know what questions to ask and what information to provide, making your visits more productive.
Track your progress
Your medical records provide a timeline of your health journey. By reviewing them, you can see how your health has changed and understand the impact of different treatments.
Although medical jargon can be confusing, don’t let that deter you. A few tips to make it easier: ask your doctor and don’t hesitate to ask your health-care provider to explain any terms or information you don’t understand.
Take notes, write down unfamiliar terms, and look them up later, or ask your doctor for clarification.
Reading your medical records might require some effort, but the benefits are well worth it.
By understanding your health information, catching errors and actively participating in your care, you can take charge of your health and ensure you receive the best possible treatment.