Accessing your medical records provides a chronological account of your health history, including details about past illnesses, treatments, and test results. Understanding these documents is a powerful step toward taking an active role in your care and making informed decisions with your healthcare team. This process requires navigating the unique structure of clinical documentation and translating the specialized language used by medical professionals. This guide provides a practical framework for reading and comprehending the information contained within your official health records.
The Standard Architecture of Medical Records
Medical records are structured so providers can quickly locate relevant information, though the format varies between inpatient and outpatient settings. Hospital records are typically more extensive than focused notes from single visits in an outpatient setting. A common organizational system for documenting a patient encounter is the SOAP format: Subjective, Objective, Assessment, and Plan.
The Subjective section captures the patient’s experience, including the chief complaint and history of present illness. The Objective section lists measurable, observable data, such as vital signs, physical exam findings, and test results. The comprehensive History and Physical (H&P) document provides a full overview of a patient’s health upon admission or for a major consultation.
Other routine documents include the Medication List, which tracks all prescribed drugs, and the Discharge Summary. A Discharge Summary synthesizes the entire hospital stay, detailing the reason for admission, the course of treatment, the patient’s condition at release, and instructions for post-hospital care.
Decoding Medical Jargon and Abbreviations
A challenge in reading your records is the specialized vocabulary and shorthand used by clinicians. Medical terms are often built from Latin or Greek roots, such as “cardio” for heart or “nephro” for kidney, which helps deduce the meaning of unfamiliar words. For example, “nephritis” combines the root for kidney and the suffix “-itis,” meaning inflammation.
Abbreviations are used extensively, and some are common and worth learning. You may frequently see abbreviations like PRN, which means “as needed,” or QID, which stands for “four times a day,” typically relating to medication dosing. Other common notations include Hx for history, Sx for symptoms, and Dx for diagnosis.
Some abbreviations can have multiple meanings, so context is necessary for accurate interpretation. For example, “PT” might mean physical therapy or a prothrombin time blood test, depending on where it appears. If you are unsure of an abbreviation’s meaning, flag it as a question for your physician.
Interpreting Diagnostic Results
Diagnostic results represent the objective data used to inform your care and fall into three main categories: laboratory tests, imaging reports, and pathology reports. For laboratory tests, the most important element is the reference range, which is the set of values considered typical for a healthy person. Your report lists your result alongside this range, and values outside of it are often flagged with a high (H) or low (L) marker.
Some lab results may be labeled as “critical values,” indicating a result far outside the reference range that requires immediate attention. Reference ranges are based on a statistical average, meaning a result slightly outside the range does not automatically signify a serious problem, as some healthy individuals may fall outside this standard. However, any deviation should be reviewed with a clinician to determine its clinical significance.
Imaging reports, such as X-rays or MRIs, are divided into the Findings section, which lists observations, and the Impression section. The Impression, sometimes called the Conclusion, is the radiologist’s synthesized interpretation of the findings and is the most relevant part for understanding the overall result. Pathology reports examine tissue samples and use terms like “benign” (non-cancerous) and “malignant” (cancerous). They also define surgical margins, where “negative margins” means no tumor cells were found at the edge of the removed tissue, suggesting the entire growth was taken out.
Understanding the Clinical Summary and Action Plan
The Clinical Summary and Action Plan is the narrative synthesis of all the data, formally documenting the diagnosis and treatment strategy. This section, often called the Assessment and Plan, consolidates the subjective information and objective results to arrive at a definitive diagnosis or a list of differential diagnoses. Physicians use classification systems, often referenced by alphanumeric codes, to formally label the patient’s condition.
The Plan section outlines the precise next steps for your care, detailing the rationale for all medications, procedures, and follow-up activities. It details the active medication list, including the dosage and frequency, and the reason for each prescription. This section also specifies expected follow-up appointments, referrals to specialists, and self-care instructions, such as dietary changes or exercise recommendations.
You may also find a prognosis, which is the clinician’s forecast of the expected course of your condition and the likelihood of recovery. The Plan clearly shows how the data from your tests informed the physician’s thinking and led to the proposed treatment strategy.
What To Do After Reviewing Your Records
After reviewing your medical records, the next practical step is to prepare a list of specific questions for your next appointment. Focus on clarifying any terms you could not decode, understanding the rationale behind medication changes, or asking about the implications of abnormal test results. Having your questions ready ensures you maximize the time you have with your healthcare provider.
You also have the right to request amendments or corrections if you believe an entry in your medical record is inaccurate or incomplete. This process typically involves submitting a written request to your provider, specifying the information you want changed and the reason for the correction. Federal laws support your right to access and amend this information. If an amendment request is denied, you have the right to submit a statement of disagreement that must be included with the disputed record for future disclosures.