Understanding your Medical Records

 

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Frequently Asked Questions

What are medical records and why are they made?

Medical records are written notes about your medical care, including what happened when you saw a clinician, your test results, and any medications prescribed.

What do my electronic records include?

Electronic records contain all the medical information that your GP stores about you. This includes consultation notes, test results (for tests that are requested by your GP surgery), prescriptions, vaccinations, and letters from hospital.

They do not include notes made about your care while you are in hospital, or results for tests that are arranged by hospital clinicians.

Why did my doctor write that I was “complaining”?

Many words are used slightly differently in medical notes compared to usual speech. We write “patient is complaining of a headache” when we mean “patient said they have a headache”. We might also write that a patient “reported” something (i.e. they told us about it). Medical language has a lot of idiosyncrasies. For example, you may notice question marks at the beginnings of words and sentences, which is used to indicate “this is possible but we’re not sure”.  

These odd and old-fashioned ways of writing have been passed down between clinicians over hundreds of years, and they go along with the Latin and Ancient Greek words that are used to describe many symptoms and illnesses.

What do the abbreviations in my notes mean?

Clinicians use a lot of abbreviations to describe symptoms, diseases, test results and treatments. Some of these (such as BP for blood pressure, and HTN for hypertension) are widely used and understood. Some can have many meanings, depending on the context (so Googling them may not provide a correct answer). Some will be related to local referral pathways and services. Different clinicians have different abbreviations they favour (for example, I often use NAD = “no abnormality detected”, but other doctors might write “normal” or “N”).

My doctor wrote that I might have a serious illness, why didn’t they tell me?

Whenever a clinician considers a patient’s symptoms, they form a “differential diagnosis”. This is a selection of different illnesses that might be causing the symptoms, and which they want to keep in mind and/or investigate. These will range from common but minor illnesses to rare but serious problems. A large part of our job is figuring out where a problem fits in this spectrum. Any problem could have one of many rare and serious causes, but we do not discuss every possible cause for every symptom, as it would be confusing and unnecessarily worrying. We do discuss likely causes, and if we feel that there is a significant possibility of a serious illness (e.g. cancer) then we will discuss this. We also keep our differential diagnosis list in mind, so that if your symptoms do not respond to treatment as expected, or if you develop new symptoms, then we may consider alternative diagnoses.

Something in my notes is incorrect. Can I get it changed?

If you believe that there are any factual inaccuracies within your medical record, you can submit a written request to the practice to have it amended. We can only consider requests that are regarding factual matters such as an incorrect date or measurement. Please note that other information, such as clinical assessments, opinions, and decisions cannot be changed. We will also not remove information that you would prefer not to be recorded in your medical notes. This includes factual matters such as weight or blood pressure, things you tell us about (such as smoking or drug use), and our clinical assessments or opinions.

If you would like to request an amendment of a factual error, please submit this in writing using our secure online form or by post to Cowley Road Medical Practice, East Oxford Health Centre, Manzil Way, Oxford, OX4 1XD. Include the change you are requesting, the reasons for your request, and your contact details.

Please note that we can not change any records that were not created by the practice, such as hospital letters.

I would like to speak to my GP about my medical records

In order to try and maximise the time GPs spend providing medical care, GPs are not available to discuss medical records. If you would like to discuss your health further, please make a routine appointment with your usual GP. Please be aware that GPs are not able to change your records.