A survey by the Medical Protection Society (MPS) reveals that 84% of doctors think that online records will mean spending more time explaining the contents of records to patients. Although doctors and the public agree the most important use of medical records is to give the doctor an overview of all the medical treatments a patient has received, there is a mismatch in expectations about how records should be written.
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Half the time doctors don't agree about language amongst themselves!
Go through papers on PubMed and you find that time and again the first issue discussed is the definitions they are using.
Simple language does not necessarily mean "simplified to the extreme and totally without technical words"! Most of us are actually happy with quite a lot of "technical" words like "temperature" (not needing it to be "how hot or cold your are"), "pulse" (not needing "how fast your heart is beating").
Indeed, when doctors attempt to simplify, they often confuse! For example, taking about someone with no thyroid suffering from an "underactive" or "overactive" thyroid! When what they are struggling to say is "under-medicated" or "over-medicated" with thyroid hormone.
I am mildly surprised that the NHS has not actually set up a formal dictionary of terms. (At least, not to my knowledge.) That would have been an obvious step. Something like that would have allowed us to look up a formal definition of Hashimoto's - instead of everyone being confused as to whether you do, or do not, have to have had a goitre!
Ho Lyn, All my my consultants and resus etc agree that my NHS records are rubbish, I have tried many times to improve this The hospital computer is too limiting.. I am told it is essential that I take a proper print out of my own, always when I go into hospital. I go every few months.. However, not nearly good enough for anything complex. I have been instructed to always take my own ( correct) details in and with me at all times. I go in every few months, always emergencies, I do not go unless blue light etc!hate them It is not very satisfactory when in a coma..
May be other people might find this useful. Only put correct doctor`s diagnosis, not what you think you have!
Best wishes,
Jackie
...the findings from a survey of the public showed that three in four (75%) agree that medical records should be written in simple language so that patients can understand them without assistance or explanation, but only one in five doctors (21%) think that medical records should be written this way.
Dr Clement picked up that Good Medical Practice which says that
Documents you (the Doctor) make (including clinical records) to formally record your work must be clear, accurate and legible.
Clinical records should include:
a relevant clinical findings
b the decisions made and actions agreed, and who is making the decisions and agreeing the actions
c the information given to patients
d any drugs prescribed or other investigation or treatment
e who is making the record and when.
and
You must give patients* the information they want or need to know in a way they can understand.
I find it laughable the Drs saying, but we will have to spend time explaining things to patients. That most of chocked them saying that.
I have just received a copy of my hospital records and they are neither clear nor legible. I am a nurse but have not worked in hospitals for many years now and thought Drs notes were supposed to have improved. Part of my job (until I was dismissed thorugh ill health) was training community health nurses on record keeping and reviewing records before release to other agencies and the courts. I have been totally shocked at how dreadful my records are with many abbreviations which I cannnot understand even with some knowledge and thought were no longer acceptable practice.
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PATIENT ACCESS INFO DIFFERENT
