Briefly unavailable for scheduled maintenance

What’s in a medical note?

A standard medical note has several sections. These include a description of current symptoms past medical problems a list of medications taken family medical history social habits such as smoking, drinking alcohol, or drug use details of the physical examination test results a discussion of the big picture, along with recommendations for further evaluation or treatment.

What’s potentially confusing about medical notes?

Most medical notes aren’t written using plain language because they aren’t intended primarily for a nonmedical audience. So it’s common to run across: Medical jargon: You had an upset stomach and a fever. Doctors may say “dyspepsia” (upset stomach) and “febrile” (fever).

What if a medical note is incorrect?

Minor errors in medical notes are not rare: maybe you had your tonsils removed 30 years ago, not 10 years ago. But there can be more important errors: stating that arthritis in your left knee is severe when it’s actually the right knee that’s severe could lead to having x-rays (or even surgery!) on the wrong side.

What if the language in a medical note seems offensive?

Numerous studies have highlighted the problem of stigmatizing language in medical notes that can leave people feeling judged or offended. Negative attitudes can affect the quality of our health care and willingness to seek care, and can also widen health disparities. One study linked stigmatizing language to higher rates of medical errors.