How can you explain medical records to patients?
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As a patient advocate, you may encounter situations where you need to explain medical records to patients. Medical records are documents that contain information about a patient's health history, diagnosis, treatment, and outcomes. They are essential for providing quality care, coordinating care among different providers, and protecting the patient's rights and privacy. However, medical records can also be confusing, overwhelming, or intimidating for some patients, especially if they contain complex or unfamiliar terms, abbreviations, or codes. How can you help patients understand their medical records and use them to make informed decisions about their health? Here are some tips to guide you.
Before you explain medical records to patients, you should familiarize yourself with the basic components and formats of medical records. Depending on the type and source of the record, it may include different sections, such as a summary, a history and physical examination, a progress note, a discharge summary, a laboratory report, an imaging report, a medication list, or a consultation report. Some records may be electronic, paper-based, or a combination of both. Some records may use standardized formats, such as the SOAP (subjective, objective, assessment, plan) method, while others may vary depending on the provider's preference or specialty. You should be able to identify the main purpose, content, and structure of each section and how they relate to each other.
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Martinien Cho
Cardiology NP | Entrepreneur| CEO & Founder (MeChi LLC)| Investor
Common mistake I often see is from one medical professional to another who happens to be the patient. Clinician providing the care, assumes that just because the patient has a medical background, they are going to understand their medical jargons In their specialty. For example, my specialty is cardiology. I certainly will hope that if I see an endocrinologist they wouldn’t assume that I know all the daily ins and outs of the words they use in their specialty.
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Luiz P.
Hospital CEO
Explaining medical records to patients involves introducing the records, using plain language, and highlighting their relevance. Key sections like medical history, medications, and test results should be briefly explained. Address patient concerns, emphasize privacy, offer copies, invite questions, and provide a summary. Ensure continued support and empower patients to actively manage their healthcare.
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When you explain medical records to patients, it's important to avoid using medical jargon, acronyms, or technical terms that may confuse or mislead them. Instead, use plain language that is clear, simple, and accurate. Plain language does not mean dumbing down or oversimplifying; rather, it is a way of communicating that respects the patient's level of understanding and empowers them to ask questions and participate in their care. To use plain language, define any unfamiliar or important terms and provide examples or analogies. Break down complex or lengthy sentences into shorter and simpler ones. Use active voice and personal pronouns. Organize information logically and highlight key points. Utilize visuals such as charts, graphs, or diagrams to illustrate or supplement the text.
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Keiko Kuykendall DNP
Stroke NP at Inova Health System
I often ask the patient/family to go to - patient portal (EMR) - relevant web sites for diseases conditions/management While we discuss the status and plan of care. Additionally, - ask the pt/family what they know and don’t know - take pauses to check their level of understanding, questions, needs etc… - ask them to take notes ( and keep it just like a diary). - ask them to check their notes to see if there’s anything they are still unclear about Another important point is - to guide them through the conversation as they tend to stray away from the core of the conversation/topics
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Sherry Picker, MSW
High-Integrity Sales and Marketing Professional with expertise in the Home Health Care, Hospitality, and Media Sectors
Show them their Medical Record. Map out the life of a Medical Record, how compiled, where it goes. when it is used and by whom Also how to make corrections to it.
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When you explain medical records to patients, you should tailor your approach to the patient's needs, preferences, and goals. Not every patient will want or need the same amount or type of information. Some patients may want to know every detail and implication of their records, while others may only want a general overview or summary. Some patients may prefer to read their records themselves, while others may want you to read them aloud or summarize them for them. Some patients may have specific questions or concerns that they want you to address, while others may not. You should ask the patient what they want to know and how they want to receive the information, and adjust your explanation accordingly. You should also check for the patient's comprehension and feedback throughout the process, and invite them to ask questions or clarify anything that is unclear or confusing.
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Anas Albashaish BSN, NCLEX-RN, AEMT
Ambulance Nurse, Advanced EMT
Individualized Care, Informed Choices Customize your approach when explaining medical records. Patient needs vary greatly. Some seek detailed insights, while others prefer a high-level overview. Ask them about their preferences and adapt accordingly. Whether they want to read, hear, or discuss their records, respect their choice. Be attentive, check their understanding, and encourage questions. Tailoring your approach empowers patients and enhances their involvement in their healthcare journey.
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Amy Tremante RN, BSN, CHPN
Palliative Care Clinical Director
Assessing the goals of the conversation should be a primary objective. Ask "what do you hope to learn today?" or "how much would you like to know about xyz?" This streamlines the conversation and ensures the patient isn't overwhelmed or upset. Not everyone wants to know the details or the prognosis. Gear the review of records to the patient's goals.
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When you explain medical records to patients, you should respect the patient's rights and privacy. Patients have the right to access, review, and request copies of their medical records, as well as to correct any errors or omissions. They also have the right to decide who can see or share their records, and to protect their records from unauthorized or inappropriate use or disclosure. You should inform the patient of their rights and responsibilities regarding their medical records, and help them exercise them if they wish. You should also follow the applicable laws and ethical standards that govern the access, use, and protection of medical records, such as the Health Insurance Portability and Accountability Act (HIPAA) or the Health Information Technology for Economic and Clinical Health (HITECH) Act. You should never disclose or discuss the patient's records with anyone who does not have a legitimate need or permission to know, and you should store and dispose of the records securely and appropriately.
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Nina Méndez
“How can I help you?” -not just a question but a way of life. A firm believer that you should always treat others the way you want to be treated. Kindness goes a long way.
It has been my experience that some people use certain words or phrases without really understanding what they mean. With that in mind, I would ask what their understanding is so that I can fill in gaps and determine how best to help them. Are they just curious? Do they need certain information? Does another provider need information? By asking questions of my own, I can determine not just their stated need, but also their unstated need.
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Anas Albashaish BSN, NCLEX-RN, AEMT
Ambulance Nurse, Advanced EMT
Patient Privacy Matters Always uphold patient rights and privacy when discussing medical records. Patients have the right to access, review, and correct their records. They can control who views their information. Inform them of their rights and help them exercise these options. It's crucial to follow laws like HIPAA or HITECH Act. Never share records without permission and ensure secure storage and disposal. Respecting privacy builds trust and ensures compliance.
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When you explain medical records to patients, you should provide support and resources to help them use their records to improve their health and well-being. Medical records can be a valuable tool for patients to monitor their health status, track their progress, communicate with their providers, and make informed decisions about their care. However, they can also be a source of stress, anxiety, or confusion for some patients, especially if they contain bad news, conflicting information, or unclear recommendations. You should acknowledge the patient's emotions and reactions, and offer empathy, encouragement, and reassurance. You should also direct the patient to any relevant or helpful resources, such as educational materials, support groups, or referrals, that can help them cope with or address their health issues. You should also follow up with the patient and see if they have any further questions or concerns, or if they need any additional assistance or guidance.
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Dominic S.
Expert Patient & Patient Advocate, YouTuber, occasional writer, fascinated by tech in Multiple Sclerosis
Ask the patient what their own aims are before assuming they are what you think they ought to/want to/need to know. Checking for understanding shouldn’t be difficult. It is so often skipped over.
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Deborah Williams, DNP, APRN, AGACNP-BC, ANP- BC, AACC
Nurse Practitioner| Educator| Mentor|Volunteer
It is essential to prepare patients for what they may or may not see in the medical record. I strive to maintain awareness of historical wrongs for specific demographics. It is essential to avoid using terminology not only above the recommended grade levels but also to avoid terms that patients may find offensive. For example, which would you prefer-"fat" or perhaps "excess body weight"? Also, please keep in mind that some demographics find the use of their first names to be disrespectful. I suggest keeping the language simple and respectful and always providing an opportunity to connect for clarification and resources to address deficiencies. While access to patient records is a positive, it can also be a bit of a double-edged sword.
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Nick Dobrzelecki
Healthcare Executive & Business Operations Leader
Components of Medical Records: Break down the typical components of a medical record, which may include: • Demographic Information: Personal details like name, date of birth, and contact information. • Medical History: Information about past illnesses, surgeries, allergies, and chronic conditions. • Medication List: A record of current and past medications. • Test Results: Lab results, imaging reports, and other diagnostic tests. • Treatment Plans: Details of past and ongoing treatments. • Doctor's Notes: Notes from healthcare providers about your visits, examinations, and discussions.
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Danny Seetaram
Customer Experience Manager | Agile Scrum Master | Driving Success Through Customer-Centric Strategies
Explain ti patients that their medical records are like a diary of their health. They tell the story of your health journey, from when you were born until now. They have information about your health problems, the medicines you take, the tests you do, and the allergies you have. They help your doctors and nurses to take good care of you. They can also help you to keep track of your health and make decisions about your care. Make them informed of what it is in the simplest terms to make them interested and engaged. This will then empower patients to explore further and ask clarifying questions to fully understand the details of their records.