There are many reasons why an individual sees a medical provider. They could be due to a new or worsening medical complaint (shortness of breath, pain or swelling) or injuries from a recent trauma (slip and fall, bicycle accident, car accident or other related injury). Depending on the circumstances, you may go to the emergency room of your local hospital or visit with your primary care physician (PCP).
There are certain things to think about when seeing a medical care provider, particularly as it pertains to your medical records. This is true for the nurse you first meet at the hospital or urgent care facility, or a physician assistant (PA) or nurse practitioner (NP) with whom you speak at your doctor’s office.
Bring a list of questions.
Write down any medical questions you wish to ask the doctor during your visit. You want to make sure to ask questions that are concerning you, and that you convey all of the important information. While you will often experience a long wait during which you can make the list, the best method is to do it ahead of time.
Carefully describe the illness or injury.
Patients need to know that every single detail they tell a doctor, particularly about the history of an injury, may not be recorded in the medical record. Choose your words carefully in order to best answer the medical provider’s questions. Give the essential points – to be sure that there is no misunderstanding conveyed.
Doctors use the SOAP method.
Medical professionals typically write notes and a report regarding your visit. When doing so, many use the “SOAP” method to compose this report.
“S” = Subjective – history and complaints described by the patient
“O” = Objective – results of testing (labs, X-rays, MRI, CAT, etc.)
“A” = Assessment – evaluation of patient’s visit
“P”= Plan – decision on the best course of treatment
When you arrive for an appointment, the medical professional, such as a physical therapist, will most likely ask how you are. Often times, a patient responds with: “I am fine (great, good).” However, that type of response does not speak to how the person is physically feeling; rather, the patient is expressing his/her mood.
When it comes to medical records, this response would be listed in the “Subjective” part of the notes. During a litigation, the response could be used by a defense attorney to try and illustrate that a patient was feeling “great,” “good,” or “fine” on that particular visit. While attorneys can sometimes overcome this hurdle in the litigation, patients should know how a simple response can be negatively interpreted.
Remember, it is your health that is the important issue. Do everything that you can to convey the essential information accurately.