Decoding Doctor-Speak

Ever wondered what the scrawl on your prescription chit means, or what your doctor's jotting in your medical file as he or she talks to you during an office visit? No, we're not referring to the oft-mentioned illegibility of doctors' handwriting - we're talking about the terms that medical professionals use when communicating with one another. 

Now, a study's underway that lets patients see their doctor's notes. It's called OpenNotes, and the Annals of Internal Medicine is one of the first medical journals to start reporting on the study's preliminary findings. This week, the Wall Street Journal also interviewed doctors and patients participating in the OpenNotes study.

Patients already have a legal right to view their medical files, with the exception of psychiatric notes, which a doctor can withhold if he or she feels it's important to do so. Usually, though, doctors don't include their notes when a patient requests a medical file. In the OpenNotes study, rather than doing their best to keep the notes to themselves, doctors invite their patients to view them.

Some patients find it beneficial to know what their doctor's thinking: it helps them take their doctor's advice more seriously, and stick more closely to prescribed health regimens. Having access to doctor's notes means a patient can quickly access information or medical advice he or she may have forgotten upon leaving the doctor's office.

Others are alarmed by what they find in their files - there may be mentions of cancer, heart disease, or confusing terminology. If all patients had access to their notes, and all doctors were required to explain these notes to patients, some medical professionals feel the burden would be too great. Doctors would spend even more time writing notes and doing paperwork than they do currently. Physicians are already leaving primary care positions because the workload is unmanageable, and the addition of an open note system may exacerbate this problem.

The OpenNotes study is a year-long endeavor, and involves 25,000 patients and their primary care physicians at Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Danville, Pa., and Harborview Medical Center in Seattle. It's funded by a $1.5 million grant from the Robert Wood Johnson foundation.


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