Language of the Medical Records

Abstract: Medical providers serve the communities they work in by helping sustain the health of their patients. In order to provide a certain quality of care, medical providers have been given tools that help support their tasks. The tool I will be analyzing is the medical record- specifically the language and structure these records contain. My goal is to compare my medical record to my patient experience. As stated by medical doctor Siegler, form dictates content. The language and structure of our medical records have a definite impact on how health care providers treat patients and how patients view healthcare providers. In order to show this correlation, I will be comparing my own medical record with my experience at the time of care. This comparison will strive to determine whether or not what my medical provider wrote about me accurately matched my perception during the visit.

Introduction: The medical record documents patient details during any hospital or clinic visit. These medical records are them complied to create the patients’ “medical history”. The medical record can date back as early as the ____’s ( , ). These paper-based records were not only illegible but referred to patients as simple subjects- the records were used to benefit the advancement of medical research rather than to actually help the patient. Today, the medical record centers around creating the best possible outcome by curating to patients. Modern medical records use descriptive language with strong structure that allow patients to better understand their state of health and plan of treatment.

Annotated Bibliography

Introduction

I will be using modern medical records that belong to myself; with dates ranging from 2015-2020. I will go through and analyze the text I’ve selected in the record and access the way the patient (myself) viewed doctors based on language used in their writing. I will also go through and ask myself the question of how the assessments documented made me feel and if I felt in good hands. How does the language affect the care of the patient? I will also be using secondary sources that have also attempted to discover what the medical record means along with its possible influence. In the end, I will look to answer my question of whether or not medical records reflect the quality of healthcare received in modern medicine.

Craig, B L. “Hospital records and record-keeping c.1850-c.1950. Part I.” Archivaria ,29 (1989): 57-87.

Craig is an archivist for York University in Toronto and previously was the archivist responsible for the records of the Ministry of Health at the Archives of Ontario. “Hospital Records and Record Keeping 1800’s – 1950’s” was her dissertation for her Doctorate Program of the School of Library Achives and Information and the University of London England. In her dissertation she goes through and give detailed accounts of how the medical record has evolved from the 1800’s – 1950’s. Craigh gives information on changes of format and structure, standardization of records, and common influences of the health record.

Saint Luke’s Dermatology Center Medical Record. November (2017)

These are going to be copies of my own medical records from when I frequently visited my dermatologist. In these records, Dr. Newland includes notes of the visit, my personal stats, and her own medical language that takes note of my condition. These are all files and descriptions for the treatments and usage of Accutane for the course of 1 year.

Jones, Steven and Cavanagh, Andrew. “Acquiring Medical Language” Chapter 1 and 2/ McGraw Hill 2nd Edition (2019)

This textbook published by McGraw Hill explores the language used in the whole field of medicine. It provides a breakdown and meaning of the words along with their importance. Chapter 1 and 2 specifically cover the topics of Introduction to Medical Language and introduction to the Health Record.

Siegler, Eugenia L. “The evolving medical record.” Annals of internal medicine vol. 153,10 (2010): 671-7. doi:10.7326/0003-4819-153-10-201011160-00012

Siegler is a licensed Medical Doctor who dives into dissecting archival medical records. In the published article she includes records from the 1800’s and works towards showing how these records reflect the quality of healthcare, personalities of physicians and evolution of structure. Siegler creates a timeline of medical record keeping and thoroughly describes certain cases from her sources.

“Words Matter: Stigmatizing Language in Medical Records May Affect the Care a Patient Receives.” Johns Hopkins Medicine Newsroom, 9 May 2018, www.hopkinsmedicine.org/news/newsroom/news-releases/words-matter-stigmatizing-language-in-medical-records-may-affect-the-care-a-patient-receives.

This article originating from John Hopkins University explores the effect stigmatization of medical language could have on the patients. This article explains that words Health Professionals choose in records could have an effect on how the patient is treated in the future or how affective their treatment might be. The article will give an expert opinion on the topic of word choice in medical records.

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