Reading Your Medical Records

Once you receive your records, please read them.

While I have plenty to be humble about as a doc, I am not shy to have you read the medical records I kept for you. As Jill said the other morning, "Medicine is not an exact science." And I replied without thinking, "Heck, it's not even a science." Which means, just about all of it is pragmatic. Yes, we docs try to understand as much as we can about the chemistry and physiology of the human system, but our knowledge is always evolving. What it usually comes down to, as you well know, is "What is likely to work and make you feel better? Let's decide if it's right for you."

So just sitting down with you and finding out what is going on, and examining you as best that time allows, and writing it all down gives me and any doc who comes after me a head start on solving the mystery, if a mystery it turns out to be.

In medical training, we were required to write complete and careful descriptive records of what patients told us and what we found on examination. Handwritten, these were usually heavily abbreviated.

"This is the 1st DH admission for this 46 y.o. MWM with ARF" translated to "first Duke Hospital admission… married white male… acute renal failure."

"Denies orthopnea, PND, SOB" translated to "… paroxysmal nocturnal dyspnea … shortness of breath", all symptoms of heart failure.

A "WDWN woman in NAD, oriented x3" was a well-developed, well-nourished woman in no acute distress who knew who she was, where she was, and the date.

We medical students learned a lot by doing these "Histories and Physicals", then reading what the experienced docs had written. Since then I have learned much by reading what my colleagues wrote about you.

I hope you learn something from ours.