Your Medical Record Is Your Story, Tell It
People often ask me, “what is a medical record?” According to Merriam-Webster, a medical record is “a record of a patient’s medical information (as medical history, care or treatments received, test results, diagnoses, and medications taken).” In other words, your medical record is your health “story.” But what’s not stated in that definition is that your medical record, *your* story, is entirely created by providers. It’s what we providers use to tell ourselves, and others, about who you are. So shouldn’t you have a say in that?
The problem with providers telling your story is that we don’t really you. And there are a few reasons for that. To begin with, we see you very infrequently and for increasingly short periods of time. But there is an even more fundamental reason – we’re not trained to document your story from the perspective of a whole person. Often, even the most well-intentioned providers narrow your story down to: age, gender, disease, presenting issue, examination, studies, assessment, and plan. Pretty impersonal.
Which of these stories paints a better picture: a “43 year-old female diabetic with a blood sugar of 180” or “Mrs. Jones, architect, single mother of two, with diabetes who was unable to pick up her medications this week because of shuffling work, kids, and family”? And which story is likely to result in better overall care? The intervention for the former might be a needless medication dosage adjustment, whereas for the latter it may simply be a change to 90-day prescriptions by mail. Same person, same condition, but different story, and different treatment.
Fortunately, we don’t have to guess about which of these leads to better results. Study after study of patient-oriented care shows that the more a patient is engaged in shaping their “story,” the better the care that patient receives. For example, a 2013 paper published in Health Affairs shows that active patients, i.e., those engaged in “shared decision making” with their providers lower costs and improve outcomes.
So don’t be passive about your medical records. Let your doctors know that you’re interested in not only accessing your records, but in helping narrate your story. Remember, if you’re not helping shape your medical record, then you’re not getting the best possible care. Your medical record is *your* story, you should tell it.
Reposted from blog.zobreus.com