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Helpful Tools for Understanding Medical Records: How to make your record- interpretation task easier

            You cannot understand your case without reading, reviewing, and digesting the medical records.  Several things – in addition to poor handwriting, for which there is no help – stand in your way:  (1) you are not a doctor, and therefore many of the terms make no sense; (2) medical personnel rely heavily on abbreviations and symbols, which you cannot interpret; and (3) the records presume that the reader understands the significance of various test results, but you have no idea if a particular result means the patient is healthy or on his deathbed.

 

            Over time, you will find that you become familiar with the most common abbreviations.  Some tests will become familiar to you.  Many terms will be understandable.  However, to be most efficient, it is helpful to obtain tools which help you make sense of the records immediately.  Here are tools I rely on and find useful:

 

I.                   Medical Symbols and Abbreviations

a.      Medical Abbreviations:  24,000Cconveniences at the Expense of Communications and Safety, 11th Edition, Published by Neil M. Davis Associates.  Includes single-user access license to internet version of the book, which is updated each month.

 

II.                Meanings of Medical Terms

a.      Dorlands Illustrated Medical Dictionary, Saunders, 29th Edition

b.      There are many other excellent medical dictionaries, including those specific to certain areas of medicine.

 

III.             Diagnostic Tests and Procedures

a.      Mosby’s Diagnostic and Laboratory Test Reference, 5th Edition, 2001

b.      Contains a list of abbreviations for laboratory and diagnostic tests.

 

IV.              Drugs

a.      Physician’s Desk Reference

b.      Nursing Drug Handbook

 

 

V.                 Other Helpful Sources

 

a.      Websites

www.emedicine.com

www.medscape.com

www.fpnotebook.com

www.medicalstudent.com

www.mythos.com/webmd

http://www.intelihealth.com/IH/ihtIH/WSIHW000/9276/9276.html

http://www.mymedadvice.com/default.asp?U=/html/O_list.htm

http://www.medicaldictionary.com/

http://www.labtestsonline.org/

http://www.merck.com/pubs/mmanual/sections.htm

 

b.      Textbooks

                                                              i.      New textbooks on the subject of interest to you are costly but current and very helpful.  Learning an area of medical information in depth can help you understand the significance of various entries in the records.

                                                           ii.      You also should look regularly at Hamilton Books (http://www.hamiltonbook.com) to get great books, sometimes for as little as $1.98.

                                                         iii.      Amazon also has a used book service and you can sometimes find used copies for a fraction of the new cost (but be careful if you don’t obtain the most current version)

 

c.        A Registered Nurse’s favorite resources:

Anatomy
www.anatomy.org/i4a/pages/index.cfm?pageid=1

Anesthesiology
www.abanes.org
www.asahq.org

Cardiology
www.acc.org
www.augusta.net/atlantic/ascp.ascpscm.html
www.asecho.org
org.umc.edu/iash/homepage.htm
www.americanheart.org

Chiropractic
www.amerchiro.org
www.accoweb.com
www.chiromed.org
www.nysca.com

Emergency Services
www.aaem.org
www.abem.org
www.acep.org

Endocrinology
www.aace.com
www.women-in-endo.org
www.diabetes.org

Gastroenterology/Liver
www.acg.gi.org
www.gastro.org
www.asge.org
www.sgna.org
www.liverfoundation.org

General Medicine
www.aafp.org
www.abms.org
www.ama-assn.org
www.ameripat.com
www.aamc.org
www.msweb.net/aaps/
www.nysafp.org
www.nycms.org

Hematology
www.hematology.org

Iatrogenic Injuries
www.iatrogenic.org

Immunology
www.ashi-hla.org/
www.aaaai.org

Infectious Disease
www.idac.org/idlinks.html
pages.prodigy.net/pdeziel/
www.cdc.gov/ncidod/id_links.htm
www.amm.co.uk/

Internal Medicine
www.acponline.org
www.abim.org
www.sgim.org

Obstetrics/Gynecology
www.acog.org
www.abog.org
www.accesspub.com/tempobg/soc/socm.htm

Midwifery
www.acnm.org

Neurology
www.stroke.org/
www.aan.com/
www.neuroguide.com/

Oncology
www.asco.org
www.cancernet.nci.nih.gov
www.oncolink.upenn.edu
www.cancer.org

Ophthalmology
www.eyenet.org
www.ascrs.org
www.asoprs.org
www.glaucoma-foundation.org/info/

Optometry
www.aaopt.org
www.aoanet.org

Orthopedics
www.aaos.org
www.sportsmed.org

Pediatrics
www.aap.org

Pharmacy
www.aphanet.org

Physical Therapy
www.aaptnet.org
www.apta.org
www.nationalrehab.org

Physiology
www.faseb.org/aps/

Plastic Surgery
www.facial-plastic-surgery.org
www.plasticsurgery.org

Podiatry
www.apma.org
www.footandankle.com/podmed/

Preventative Medicine
www.acpm.org

Psychiatry
www.abpn.com
www.psych.org

Pulmonology
www.lungusa.org
www.aarc.org/
www.chestnet.org/
www.thoracic.org/

Radiology
www.asrt.org
www.rsna.org
www.acr.org

Rheumatology
www.rheumatology.org
www.arthritis.org

Surgery
www.facs.org
www.acfas.org (foot and ankle)
www.fascrs.org (colon and rectal surgeons)
www.womensurgeons.org

Urology
www.auanet.org
www.kidney.org

Vascular Medicine
www.svmb.org

Veterinary Medicine
www.abvp.com
www.avma.org

Medical Terminology
mywebmd.com/encyclopedia
www.nlm.nih.gov/medlineplus/mplusdictionary.html
medmatrix.org
home.ipoline.com/~guoli/med/Ohead.htm
www.edae.gr/dictionaries.html
www.medicinenet.com (then click on dictionary)
www.4woman.org/nwhic/references/dictionary.htm (online dictionaries and journals)
courses.smsu.edu/jas188f/690/medslpterm.html
www.thebody.com/treat/gloss.html

Large Listing of Medical-Related Sites
www.sciencekomm.at/links/medicine.html

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