Home > Health, Mobilehealth, TechMed > Medical Records were not meant to be “Sugarcoated”

Medical Records were not meant to be “Sugarcoated”

I have spoken recently with several doctors that are changing the way they write their notes and thus relevant patient information. Why? Simple, a great thing is happening, patients are beginning to embrace digital health , learning more about their diseases/conditions and accessing, studying and understanding their medical records.

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Here is the kicker…Sometimes in life we hear others addressing personal issues that even though they are true, they are uncomfortable to hear. Some can easily ignore them, others may  feel insulted and/or aggravated. This is extremely important to YOU, yes you who is reading this, since you now  have easy access to your Medical records.

Medical records are not meant to be a story. They were not made to be easy on our ears. They are scientific data used to capture facts. They are the mixture of years of training, medical knowledge, experience, and a patient-doctor relationship.

Alison-Brie

Why is this important?  A chart might say; Mr. X is a delightful, pleasant individual, who exercises daily and is very involved with his health. Fantastic right? Well yes but the opposite is true. Mr. X can also be obese 57 year old individual, with a 20 pack year history who is not compliant with his medications. Mr. X mentions that he has no money for his medications but yet he is able to buy  a pack a day of cigarettes. The latter, mentions facts that are not pleasant to hear but may be the truth.

I am now encountering physicians, being contacted by their patients, arguing that they do not appreciate being called obese in the note. They do not appreciate hearing that they are not compliant  when obviously they are not.  Since physicians do not want to aggravate more people then they reword or  simply refrain from placing particular information in the chart. Information that other physicians will find valuable because it can change the way they will address the case.

Bottom line is, when WE encounter this situation, before WE get angry we have to  reflect and ask ourselves, “Is this true?”

I have modified my lifestyle thanks to comments like this. Comments that were not easy to digest but the truth nonetheless.

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September 27, 2014

* EDIT1: If you would like to engage on a conversation regarding this post, it has been posted in reddit http://www.reddit.com/r/medicine/comments/2hkzag/are_we_entering_the_era_of_sugarcoating_medical/

* EDIT 2: Thanks to Dr. Jack Minas for sharing  “Interview with Eric Topol: Do Docs & Patients See Eye-to-Eye?” Interesting comment here “54% of patients say they own their medical records vs 39% of doctors who say they own them. Although there is confusion on the part of doctors and patients, but some medical associations are pretty clear that the records belong to physicians. Check this out: The Texas Medical Association states, “Although the medical record contains patient information, the physical documents belong to the physician. Indeed, the medical record is a tool created by the physician to support patient care and is an asset of the practice.”

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