What would you find in your medical records?

Exactly what is in your personal medical record – the paper file in your family doctor’s office or the electronic record in the clinic’s computer? What key information should you know by heart or at least have at your own fingertips?

With every medical visit, your doctor will create an entry either written in a paper chart or typed into an electronic record. In both cases, an entry must be dated and usually follows the standard SOAP format.

S stands for subjective: what you describe to the doctor. This includes the key details of the history of your symptoms, such as the type of pain you have been experiencing – its location, quality, intensity and duration, what makes it better and what makes it worse.

O stands for objective: the results of previous investigations and the findings on the physical examination. This includes what the doctor sees or measures, hears with the stethoscope and feels on palpation.

A stands for assessment: the diagnosis or multiple possible diagnoses we want to confirm or rule out.

P stands for plan: the investigations or treatment offered or recommended.

Doctors are required to write these clinical notes in such a way that it is clear what was found on examination, what the doctor was thinking and what was discussed with the patient. They should be written in such a way that another physician would be able to follow the doctor’s logic and know what the next steps would be.

Before I step into an examination room, I review the previous visit and any reports or test results that have come in since then. After each visit ends, I spend a few minutes completing the chart notes.

If there is time, I’ll complete the forms or write the letters required for more extensive investigations or referrals to specialists, but usually I’ll complete these at the end of the workday.

Also within your medical record are the results of investigations, including x-rays, scans and lab tests; admission, operative and discharge reports from hospitals; and the consultation letters from specialists. These are filed in specific sections in chronological order in both paper and electronic charts.

In every paper chart (usually the inside cover) and in every electronic record should be a summary of the key information from a patient’s medical history. This is the information you should know by heart in case you have to see another doctor in a different clinic or ER: drug allergies, current medications (their doses and directions), significant past illnesses and hospitalizations, current and chronic medical conditions (such as high blood pressure or diabetes), previous operations, significant medical procedures (including their dates) and your family history.

If you don’t have all this information, ask the staff at your family doctor’s office to help you fill in the blanks. However, be patient with them. Medical office assistants are the backbone of the clinic, working hard to support both patients and physicians, making appointments, organizing tests, arranging referrals, filing results and reports, and ensuring your records are secure.

Dr. Davidicus Wong is a family physician at the PrimeCare Medical Centre. His Healthwise column appears regularly in the Vancouver Courier, Royal City Record, Burnaby Now and Coquitlam Now. He is a regular Tuesday morning guest on Jill Krop’s AM/BC talk show on BC1 (channel 21 on Shaw). 

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About Davidicus Wong

I am a family physician. I write a weekly newspaper column, Healthwise for the Vancouver Courier, Burnaby Now, Royal City Record and Richmond News.
This entry was posted in Medical Ethics, patient-doctor relationship and tagged , , , . Bookmark the permalink.

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