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15 terms you might see when you look at your medical records and what they mean

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15 terms you might see when you look at your medical records and what they mean

While the past year has provided a tremendous amount of daily medical news since the start of the COVID-19 pandemic, a small item Looks like it’s been spied on: New US federal policy requires healthcare providers to make your medical records easy for you, with an associated fine if they don’t do that. Much of this information was technically available before, but given the way the US health care system works, it can be very difficult to find.

This means that you may find yourself peeking behind the curtain with some of your doctor’s detailed notes and summaries in a way you’ve never done before. Records may contain confusing terms or jargon, most of which are designed for healthcare providers who are communicating with each other. The goal isn’t difficult, but you may want help understanding some key terms.

Guava health compiled a list of 15 terms that might show up on a patient’s medical record, determined what they meant, and explained what might be covered in those terms, using information from physicians. doctors, health journals and other health professionals. While you may still have questions to ask your doctor, this list will hopefully give you a lot more confidence in reviewing your medical records after your next visit.

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Medical history

Your doctor, especially a new doctor, will compiling medical history Indicate your allergies, past illnesses and surgeries, and any medications you have taken or are still taking. Additionally, this will usually include your family history of serious illnesses, as there are genetic factors that can be passed down through generations. The purpose of your medical history is to help your doctor understand any other factors that may affect the reason for your visit.


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Social history

Your social history usually a subset of the general medical history that also includes past illnesses and conditions. Questions will likely include issues like legal and illegal drug use, sexual history and behavior, and even be as specific as your occupation — all factors that may be involved regarding any treatment you need. A lifelong smoker with a dry cough has a different patient profile than someone who has never touched a cigarette — both of which must receive the best personalized care.


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Allergy

During your examination, your doctor will Ask about your allergies. Of course, this should include any medications, but can also include “regular things” like lactose or eggs. Both of these food-related substances are commonly used in medicines and can cause reactions in people with severe allergies. Ultimately, the goal of allergy logging is to make sure you’re not taking a medication you’re allergic to.


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Immunizations

Immunizations, or vaccines, are an important part of your medical history. For young children, this information is important to ensure they are up to date with the vaccines they need. For adults, it is still important to find case-based vaccines such as tetanus vaccine, as well as the availability of vaccines such as HPV vaccine when eligible. events change with age.


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Recently completed tests

Any medical facility should have a list of tests you’ve had recently as a form of record keeping as part of your medical history. This helps your doctor make sure they don’t order duplicate tests and also helps them know about the results that will be available to them as part of your record. Test results can also explain why specific medications or procedures were prescribed.


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Original Terms

The original terms usually refer to an organ, tissue, or condition. Many medical words are put together from pieces of ancient Greek or Latin. The term “stress”, like hypertension and hypotension, refers to blood pressure. You can see – pain, that is, pain, like neuralgia and fibromyalgia. The root word -ema, meaning blood, is found in terms like edema or anemia.


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Original descriptive prefix or suffix

Hyper- and hypo- are prefixes commonly used in the medical world. Hyper- means above or high, while hypo- means below or low. Hypoglycemia, for example, refers to low blood sugar, compared to hypertension, which means high blood pressure. Hypo- also appears in terms like “subcutaneous”, which refers to the needle passing under the skin, while “hypothetical” means under consideration.


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Procedure Notes

Procedure Notes record a series of facts and observations related to procedures you have had, such as stitches or endoscopy. Your doctor will likely note what led up to the procedure, any other tests or indications involved, and how the procedure itself actually went. The notes will also include logistical things like who checked in and where and when.


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Progress Notes

Progress notes often involve hospitalizations over a multi-day period. The notes will reflect changes in the patient’s condition, which is especially important when the patient is recovering from surgery, for example. Progress notes are also a way for a team of medical professionals to check each other’s observations of a patient.


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Access summary

A visit summary includes basic details about your visit with your doctor or health care provider. It must include the purpose of the visit, what was discussed, and any procedures or medications to follow during the visit. Opposed to clinical notes, the exam summary is designed to be readable by the patient, so it explains things more clearly.


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Code CPT

The system of Code CPT is a way for everyone from doctors and nurses to insurance providers to make sure they know exactly what procedure has been performed. Like the Dewey Decimal System used in libraries, medical providers use CPT codes to keep records clear and concise that everyone involved can easily interpret.


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Reference range (lab results)

For many medical tests, the results are dynamic and do not correspond directly to something like a percentage. You will get raw numbers that represent your cholesterol or blood sugar or whatever else. A reference range is a set of values ​​given to you as a frame of reference to help you understand your results, much like the “sane range” of results for a test.


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Lipid panel: LDL vs. HDL

Low-density lipoprotein (LDL) and high-density lipoprotein (HDL) are two forms of cholesterol measured using a standard lipid panel. HDL is the “good” cholesterol, with higher values ​​corresponding to a lower risk of cardiovascular disease and stroke. HDL is eliminated from your body through your liver, which is designed to process fat. Instead, LDL, the “bad” cholesterol, builds up in your arteries and can lead to heart disease.


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Complete blood count (CBC)

ONE complete blood count it sounds like it: a medical survey of all the different parts that make up your blood, each of which may have a cause that needs to be evaluated later. Measured items include red blood cells and white blood cells as well as hemoglobin and platelets. Elevated white blood cells, which are responsible for fighting disease, can indicate underlying conditions such as cancer.


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Basal metabolic panel (BMP)

While a complete blood count measures the materials that make up your blood, basal metabolic panel Measure eight substances that are diluted in your blood. These include glucose, or blood sugar, as well as electrolytes and waste products such as urea. A basal metabolic panel can help your doctor pinpoint problems like high blood pressure, kidney disease, or diabetes.

This story originally appeared on Guava health
and is produced and distributed in partnership with Stacker Studio.


https://kesq.com/stacker-science/2021/12/09/15-terms-you-might-see-when-looking-at-your-medical-records-and-what-they-mean/ 15 terms you might see when you look at your medical records and what they mean

DUSTIN JONES

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