Have you ever left a doctor’s appointment feeling confused by all the medical jargon and shorthand notes? Those cryptic scribbles may seem like an alien language, but they provide valuable insight into your health condition and care plan.
The Basic Structure
Despite their messy handwriting, most physicians follow a standard format called SOAP notes:
- S – Subjective information from you, the patient’s perspective.
- O – Objective observations and clinical findings.
- A – Assessment of the patient’s condition.
- P – Plan for treatment or further testing.
This simple organizational method ensures your doctor captures all the relevant details in a logical order. It also creates consistency across your medical records.
The Subjective Section
In the subjective (S) portion, your doctor summarizes what brought you in for the visit and the symptoms you described in your own words. This could include:
- CC – Chief complaint (“fever and body aches”).
- HPI – History of present illness (“Started 3 days ago after traveling”).
- ROS – Review of other related systems (“Also experiencing cough and fatigue”).
Understanding your initial complaints and how symptoms developed helps provide context around potential diagnoses.
Objective Data Points
Next comes the objective (O) clinical information your doctor gathers through examination and testing. This is where you will find lots of abbreviations and shorthand, like:
- VS – Vital signs (temperature, blood pressure, etc.).
- PE – Physical exam findings (“lungs clear, no swelling”).
- DX – Diagnosis details..
- Labs/Rad – Results from lab tests and imaging scans.
These objective metrics and observations help rule out or confirm possible health issues based on your subjective symptoms.
Assessments & Plan
After reviewing subjective and objective information, the assessment (A) section identifies the doctor’s conclusions about your condition. This could range from specific diagnoses to descriptors like “dehydration” or “diabetes, uncontrolled”.
Your doctor may use ICD 11 diagnosis codes here – the latest standardized system for classifying diseases and health problems with code numbers. The good folk over at Find-A-Code.com explain that these ensure everyone understands exactly what is being documented.
Finally, the plan (P) outlines recommended treatment, procedures, medication prescriptions, specialist referrals, and any other instructions. For example:
“P: Start amoxicillin 500mg bid x10d, f/u in 2 wks”
This means take amoxicillin antibiotic twice daily for 10 days and follow up in 2 weeks.
Common Shorthand
Get ready to see plenty of other shorthand abbreviations scattered throughout, such as:
- Hx – History or medical background.
- Fx – Fracture or broken bone.
- CP – Chest pain.
- SOB – Shortness of breath.
- N/V/D – Nausea/vomiting/diarrhea.
- HA – Headache.
- PMH – Past medical history.
- Meds – Medications.
- Wt – Weight.
- Ht – Height.
While it looks like code at first, all these shorthand notes help efficiently document important information in your record.
The Importance of Communication
Of course, doctor’s notes alone do not tell the full story of your care experience. Clear communication during the actual visit is essential for your doctor to fully understand your condition and for you to understand the explanations and instructions given.
Don’t be afraid to speak up if any part of the assessment or plan seems unclear. Asking questions ensures you and your doctor get on the same page about managing your health.
Accessing Your Medical Records
Remember, you have a legal right to obtain copies of your full medical records, including doctor’s notes. Reviewing them in detail can help you better understand your care.
Many providers now offer online patient portals that allow easy access. Or you can formally request printed copies, which may involve fees.
Conclusion
While the shorthand and medical terminology may still seem confusing at first, having your doctor’s detailed documentation can provide crucial insights into your healthcare journey over time. It is an invaluable resource for staying informed.
