Doctors notes will aid private investigators according to the OpenNotes project.
A study currently under way, called the OpenNotes project, is looking at what happens when doctors' notes become available for a patient to read, usually on electronic medical records. In a report on the early stages of the study, published Tuesday in the Annals of Internal Medicine, researchers say that inviting patients to review the records can improve patient understanding of their health and get them to stick to their treatment regimens more closely.
But researchers also point to possible downsides: Patients may panic if their doctor speculates in writing about cancer or heart disease, leading to a flood of follow-up calls and emails. And doctors say they worry that some medical terms can be taken the wrong way by patients. For instance, the phrase "the patient appears SOB" refers to shortness of breath, not a derogatory designation. And OD is short for oculus dexter, or right eye, not for overdose.
Doctorspeak
Terms physicians use in their notes that could be confusing to patients:
SOB- Shortness of Breath.
NERD- No evidence of recurrent disease.
Thrill- Sound or movement felt on chest wall with an abnormal heart
Shotty Mildly enlarged lymph nodes.
Somatizing- Complaints of physical symptoms with no physiological origin
Flat affect Expressionless face, which can mean depression, schizophrenia, or nothing.
Demented- Medical term for memory loss, inability to learn new materials
Imp Short for impression; doctor's conclusion of patient's condition
Patient denies- Patient reports no symptom.
Congestive heart failure- No literal failure; a manageable heart condition.
Crackles/Rales- Lung sounds that indicate respiratory disease.
Sources: Annals of Internal Medicine, medicinenet.com
Links: http://www.medicinenet.com/script/main/hp.asp
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