The Truth about doctors notes and your sanity

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Can you handle the truth? Seriously, can you handle it? Imagine you could see everything that your doctor was writing down while he pressed on your stomach, looked in your ears and asked you about your diet. It would most certainly be a wealth of information. To the uninitiated, or those not involved in the medical community much of the terminology may look like a foreign language. However, the truth is most patients would be shocked if they could see what doctor’s notes actually say. One might imagine that they just cover simple things like temperature, weight or how clear their airway sounded under the stethoscope, but it goes much further than that.

Real doctor’s notes are very in-depth. They cover everything that could help a clinician to make a diagnosis and efficiently treat a patient. That being said, they could be totally brutal for someone who doesn’t know what they entail to read. They don’t just include the absolute basics of a medical exam, but they include notes about the patient’s appearance, their overall demeanor and many more little details that would be shocking to someone that has never seen doctor’s notes as they are written. There are many privacy laws in place to protect the secrecy of individual’s doctor’s notes and what is written in the electronic medical record, but for the most part the general public has no idea what is written in their own doctor’s assessment. Doctors will generally give their patients a rundown of what their plan of action is, their diagnosis and other small details. They usually leave out their findings that may be somewhat uncomfortable but not relevant to their diagnosis or health. The biggest issue is probably that not only do doctor’s notes cover their physical findings from the exam, but they also cover what the patient discussed with their clinician. This could be problematic for those who are trying to join the military or other organizations that have stringent medical background checks. The truth is this: as long as insurance is used, the medical record will last for a lifetime

This creates a genuine problem for those who must use their insurance for a physical exam. In many ways, their visit to the doctor becomes a legitimate test, if they are in a position where their physical health could become a disqualifying factor for their job. This becomes increasingly problematic when we come to the area of mental health. Most people go to see a general practitioner for their yearly physical. While generalists are usually required to do a psych rotation during medical school, it often falls to the wayside as they are regularly seeing other disease presentations during the height of their career. When a physician is strained with so many different areas to cover, the doctor’s notes may become hazy and not a clear picture of the overall health of the patient.

In many ways, this is the challenge our modern healthcare system faces. A human being confronts life from many different angles. There is the physical and physiological sense in how our body functions and there are also the psychic and mental areas that are not as quantifiably tangible. The real challenge is how well a simple doctor’s note is able to approach these complex realms.