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

by Kelly Centofanti

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, 11^th 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, 29^th 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, 5^th 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