How can you explain medical records to patients?

Usability and perspective are what come to mind. Programming the Epic (EHR) has taught me to take a holistic approach by including how providers work daily and mesh that with drastically improving patient care. My objective as a consultant is to provide the standard for doing things the right way, not always the easiest way. This means keeping verbiage in plain language that anyone can understand without getting confused. I may see that alerts are popping up everywhere in patients charts and driving physicians crazy but not providing any value, so let's evaluate and turn those off. In another case, the discharge summary fails to give patients the direction they need after they leave the hospital. Empathize and correct.

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.

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.

When explaining medical records to patients, it's crucial to clearly describe what the records contain, like diagnoses, treatments, and test results, in simple language that they'll easily grasp. Reassure them about the confidentiality of their records and emphasize the impact of these records on their ongoing care. Encourage questions and interactive discussions, ensuring patients feel empowered to access and understand this crucial information that shapes their healthcare journey.

I have one rule of thumb for explaining medical items to patients. If your explanation cannot be understood by a 7-year-old, it probably needs to be simplified. You will need time to teach. There are better situations than the standard 10-minute appointment for this type of teaching. Assess whether the patient has the emotional capacity to retain what you plan to teach. If the patient has received a life-changing diagnosis, it isn't the ideal time to transfer large quantities of information. Does the patient have someone who can accompany them to the teaching appointment? Schedule a call (they have had time to talk it over with friends and family) within a week of the teaching to answer new questions and ensure they understand.

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

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.

✅Using Plain Language: - There's no doubt that this is the easiest and most important way to become a respected medical professional by patients. 💡 The clarity you give patients by using plain language is unmatched. You are able to show them respect whilst encouraging questions and active participation where appropriate. 📝 And if you really can't get away from using some unfamiliar terms, make sure you offer examples and explain it thoroughly by using visuals like drawings or charts that the patient can take home with them.

As a dental professional, I often find flip charts a useful way of explaining certain types of dental diseases, such as Periodontal disease. Patients often find visualisation a useful way of understanding a topic. I use patient friendly terms such as 'Gums' rather than 'Gingivae'. Sometimes it's important to remember that the majority of patients may be alienated by confusing medical jargon and this can increase anxiety. Some patients may know more than others, having a discussion about their current grasp of a topic can be an insightful way of gauging their understanding.

Using plain language is critically important in breaking down complex medical conditions in a simple manner. Also, an effective way to check to see if language is understood is to pause and to ask a clarifying question, such as "do you know what I mean when I say colonoscopy?" This will allow the opportunity to further explain a colonoscopy as a procedure before going into further conversation. Using photos, graphs, charts, numbers, etc. can be helpful to further illustrate points.

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.

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.

🥼A skilled medical pro knows how to tailor explanations to patients. It's about crafting the best experience, especially during a tough time in their lives. 💘This personalized touch might come from years of working with a patient, or it could start anew. ❓So you might need to ask some questions to find their preferences, like: -Do you prefer discussing things face-to-face, over the phone, or via email? - Is there anyone you'd like involved in discussions about your health, like a family member or caregiver? - Are there cultural or religious considerations I should be aware of when discussing your health? 📑And ALWAYS end with this one: Are there any particular concerns or worries you'd like us to address during our discussions?

Patient education about medical records is critical to increase personalized health in the long run. Yet, patient awareness and digital adoption depends on so many variables. Identifying the unique need that a unique patient has at the first medical encounter will help to roll out the right explanation and the one story the patient will relate to. Building credibility and trust with patient is key. Explain how access to data is important for treatment optimization and follow-up i.e. 'vitals are good, no need for additional blood work, no need for additional CT scan, meds can be reduced so less side effects... ' etc. Focus on the patient benefits for their very own condition.

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.

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.

💡I always suggest providing patients with accessible information upfront rather than waiting for them to ask for it. Many might not even realize that this option is available to them. 🥼Especially during a stressful time, it's crucial to reassure patients that their records are confidential. I made it a point to highlight that we will never discuss or disclose their information without legitimate need or permission. 💪It's a vital reminder for them and it helps in building a strong patient-professional bond.

The first thing is to assess the person’s capabilities and present the information in a way it can be easily understood by your patient.

Es crucial encontrar estrategias que salvaguarden la privacidad de los datos del paciente sin dificultar la colaboración interdisciplinaria. Esta colaboración es fundamental para detectar factores omitidos y prevenir posibles riesgos no considerados previamente. Respetar los derechos y la privacidad del paciente no solo es ético, sino que también es esencial para construir un entorno médico que fomente la confianza y el cuidado integral del paciente, mientras se garantiza la seguridad y confidencialidad de su información médica.

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.

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.

I like to use this opportunity to educate patients on how they can be more autonomous in their health by utilizing the online patient portal associated with the health system, if one exist. Once a patient understands where they can go when they have questions, and sees how to arrive at solutions on their own, they have better overall outcomes in their own personal healthcare and well-being.

🗣️Explaining medical information can be tricky, right? It's super important to keep things crystal clear, especially since patients minds can get a bit foggy during these talks. So, jotting down key info on paper for patients to take home can be a game-changer!! 🎨Oh, and don't worry about being an artist! Simple diagrams or sketches can really help in making explanations easier to grasp. Sometimes, a little doodle goes a long way!

Patient Support and Empathy Explaining medical records can be overwhelming for patients, so provide the support they need. Understand that records can evoke various emotions, like stress or confusion. Offer empathy, reassurance, and encouragement. Share helpful resources, such as educational materials or support groups, to assist them in managing their health concerns. Keep the conversation open for questions and follow up to ensure their well-being. Your support is a crucial part of their health journey.

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.

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.

In hospital setting, I always ask the patient/family to get “discharge summary” from medical record if possible. After visit summary from EMR is useless when the outside providers need to know what happened to the patient during the hospitalizations.

As a general rule of thumb, medical records contain personal health information (PHI) that is confidential. PHI should only be shared with those in a healthcare team if they are directly involved in the circle of care. Patients and HCPs should be mindful that there are laws that govern how medical records are accessed and otherwise used. It is important to note aspects involving informed consent and custodianship related to medical records. Overall, complete documentation of all interactions with the patient and/or their SDMs/PoA (Health) contributes to the narrative and health history of each patient, and this guides HCPs in their provision of care. Consider consulting with your regulatory body if there are concerns around medical records.