All of us have access to our medical records whether it is a dedicated app or access to a patient portal of some form. This was made possible by the Cures Act in 2021 where it was mandated that patients have access to their medical information. When you see your primary care provider (PCP) and have some labs drawn, magically you get sent the results before you hear back from their office about what the results mean. Why though? You don’t know what the tests are or the numbers you get and when you read your medical note, you’re left confused. In this post, I want to help demystify what all this information means and empower you for when you next access your own medical record.

To start, you might ask yourself why is it important you have access to your own medical record and can see all that information. Even though you might not know what you’re looking at, it’s helpful to have that information so you can ask specific questions about the various details you have access to. Also, while you might think providers hate when patients google information online, we encourage it so that you can be informed about your questions. However, we ask that you use reputable sources like medlineplus.gov. If you get a certain value back from a particular lab test and look up what it could mean, it will help you formulate questions to then ask your provider if it isn’t brought up by them specifically. For example, if you had a complete blood count (CBC) and your white blood cells (WBC) were slightly elevated you may google it and find a number of reasons for this including cancer, infection, medication side effects, stress, or autoimmune conditions. You can then go to your appointment or respond to the message your provider sends you by asking why your WBC count is elevated. This is important because as clinicians we do a lot of thinking in our heads and sometimes forget to explain why something is considered “normal” even though the value is technically abnormal. Maybe you were recently on high dose steroids and this is why your white blood cell count is mildly elevated which is why it wasn’t specifically discussed. Also, clinicians are human and we sometimes make mistakes. We may overlook something that you picked up on and you can ask pointed questions about. As a patient safety leader for many years, this is unfortunately a common problem that technology is trying to fix.

Now that we talked about why having this information is important, let’s dissect the anatomy of your chart. It usually consists of five sections including: problem list, medications/allergies, lab results, diagnostic results, and visit notes. Let’s break down each one and why it is helpful to review that information.

First let’s dive into the problem list. The problem list is all the diagnoses you have so that anyone looking at your chart understands what your full clinical picture looks like. Usually it contains formal diagnoses like hypertension (high blood pressure), type II diabetes, and major depressive disorder but can also include historical conditions like history of prostate cancer, history of pulmonary embolism, or history of left hip fracture or active symptoms like wheezing, knee pain, or dizziness. When a clinician is confident in a diagnosis and the presentation meets diagnostic criteria, they will document the formal diagnosis on the problem list like type II diabetes or generalized anxiety disorder. For historical conditions, it’s important to to include diagnoses that are no longer active but could impact future care or are important to consider in the context of a patient’s history. For example, knowing someone has had history of a left hip fracture can be important if they present with new onset of left hip pain because the clinician may have a higher concern for a new fracture in that same hip. Symptoms are included on the problem list when there is uncertainty as to what the actual cause for the symptom may be and the provider wants to follow its evolution over time. As an example of this, if a patient has shortness of breath on their problem list, there could be a number of reasons for this. The clinician is then going to determine the cause through history, examination, and testing. It could be heart-related like heart failure, lung-related like asthma, or infection related like pneumonia. Once they establish a diagnosis through that process, that symptom on the problem list is changed to whatever the new diagnosis ends up being (e.g. wheezing changes to asthma). In addition to the type of diagnoses you’ll see on the problem list, you’ll also notice a number of abbreviations. Medicine is filled with alphabet soup, acronyms for so many different things. If you see an abbreviation on the problem list you can search on medlineplus.gov or ask your provider to clarify what it means. You may have high blood pressure and you may even know that it is officially called hypertension but it is often abbreviated as HTN. If you have diabetes, you may see DM I or DM II to represent type I or type II diabetes. If you aren’t sure what is on your problem list, ask your provider and they will be happy to clarify. It’s important to understand what is on your problem list because you may see something on there that you weren’t aware you had. Often times this is because we call it something more technical than what the lay term may be like hypertension and high blood pressure. There may also be something that was carried over from a previous primary care provider or was inaccurately documented on the problem list that you noticed and can request to be removed or corrected in your medical record. So check your problem list and ask questions to clarify what is on there if you aren’t sure.

The next part of your medical record is your medication and allergies list. First and foremost, always look at your allergy list. Make sure it is accurate and complete because if it is missing an allergy, a provider may prescribe something that you’re allergic to which could have dangerous results. Or there may be something listed as an allergy but maybe you just experienced a side effect and you want it to be corrected as an intolerance and not an allergy in case you need that medication in the future. As for the medications list or “med list,” it’s important to make sure this is accurate. There’s a few reasons why you want your PCP to have an updated, complete, and accurate med list. First, you may be prescribed medications by other providers like specialists, urgent care clinicians, or hospitalists and it is important your PCP knows all the medications you are taking in case they need to prescribe something else or understand a symptom that may be a side effect. Second, medications often interact with one another and your PCP has a bird’s eye view of your entire clinical picture. So they can look at all the medications you are prescribed from various sources and determine if there are any interactions that could cause you harm. Your dermatologist might not know you are taking warfarin (a blood thinner) and prescribe you a common antibiotic known as trimethoprim/sulfamethoxazole for a skin infection. Let’s say you then have a follow up with your PCP who sees that you were prescribed Bactrim. They may switch the antibiotic immediately and order a blood test to check how quickly your blood clots because trimethoprim/sulfamethoxazole and warfarin can lead to dangerous bleeding. Always review your medication list and make sure it is up to date. You also want to let any clinician know if you are taking a supplement or over the counter medications. Herbs, supplements, and over the counter medications can have dangerous interactions with various health conditions or medications like bleeding or liver/kidney toxicity so it is important for them to be aware of any pills you are taking (as “natural” or “harmless” as they may seem).

Like we discussed in the beginning of this post, your medical record contains lab results. This is most often where patients interact with their medical record. They see their clinician, have labs drawn, and then get the results not knowing what they are. This often includes blood tests, wound/skin cultures, and urine testing. If you have these tests done, they will show up in your portal as soon as they are processed. Sometimes this is hours from the time of the appointment or it could be days from when you had them drawn. It all depends on what kind of test it was as some can be processed immediately in the office while others need to be sent to an external lab center for processing (and take varying lengths of time). You then get these results before the provider has even had time to review them, now what? Well, often times, if the clinician has the time, they will usually explain what they anticipate they will see and generally what the labs mean if they are high, low, or normal. For example, when I send someone for cholesterol testing, I will explain that their LDL and triglycerides are their bad cholesterol and their HDL is their good cholesterol. If I have the time, I may also explain what causes these things to be high or low and how to counteract that through diet and lifestyle. Unfortunately in traditional healthcare settings like your primary care provider, they often only have 15 minutes with you so this often doesn’t happen. So if you do get your labs before the provider calls or messages you, you can certainly go online and search what these values mean. Websites like testing.com or medlineplus.gov are reliable websites that give helpful information about all kinds of lab tests and what the results mean. This can then help you formulate questions like “why is this high when I am taking a medication for my cholesterol?” or “if this is low, I read that could mean I have [x] condition.” By asking these questions your provider can then gauge your understanding of your health and tailor their response appropriately to give you the best means of improving it.

The next part of your medical record is the notes section. Most often, health system portals and patient apps let you look at visit notes from clinicians you’ve seen. These are how we as providers communicate to one another what was discussed, what happened during the visit, and why certain tests or treatments were considered. You will see the HPI (history of present illness) which is typically at the beginning of the note. This is what we refer to as the subjective portion of the note where we talk about your medical history, what brings you in for the visit, as well as what was discussed by you as the patient. If you come in for a cough, we may document something like “52 year old female presents today with a cough x 2 weeks that is nonproductive without shortness of breath and fever. Started after working outside in the cold, no sick exposures, and has tried tea with honey and over the counter cough medicine without much relief. Admits to some wheezing. No history of asthma or other respiratory diagnosis.” You will often see your med/allergy list, problem list, and sometimes your past medical history or PMH. The difference between your problem list and past medical history is that the problem list is all your active problems and pertinent historical conditions. PMH is everything you’ve ever had (may not be entirely complete but pretty long). Then you will see what is referred to as the objective portion of your note that includes your vital signs and examination findings for the visit (anything that is objectively measured or examined). Vital signs are usually your temperature, oxygen reading, weight/height and body mass index (BMI), blood pressure, and pulse depending on what was measured at that visit. The exam is all the findings or lack of findings that a clinician conducts such as when they listen to your heart or lungs, look in your ears, or check your eyes. The last part of the note is what is known as the assessment and plan, and to some, is considered the most important part of the note. It establishes the diagnoses addressed during the visit, what’s going on with each diagnosis, and what is the plan to monitor, evaluate, or treat/manage them. Sometimes you will also see what orders were generated during that visit such as labs, imaging like ultrasounds or X-rays, or referrals to specialists.

Lastly, your medical record will show testing results outside of labs; things like echocardiograms, ultrasounds, or x-rays. While diagnostic tests are even more complicated than interpreting labs sometimes, it is important for patients to look at these results. You may read something that is concerning to you and it could prompt an important conversation with the ordering provider to allay any fears or concerns. In addition to this, often times radiologists may include a lot of information in the findings section of the imaging report but the impression is short and does not refer to a specific finding. In my experience as a patient safety leader and treating provider, I have seen worrisome findings in a diagnostic report that was omitted from the findings in error. So as a patient, you are the best steward of your health so read those reports and if there is something that sounds concerning and is not represented in the findings, ask the ordering provider if it is something that requires attention.

As you can see, your medical record is a cornucopia of information that can be disorienting and confusing when you aren’t sure what you’re looking at. Now that you understand the anatomy of your record, take a look and make sure your record matches your health and medical history. If something seems off or doesn’t fit with what you thought about your health, have a conversation with your PCP because there may be some nuances you are missing that requires some discussion or in some rare circumstances, corrections that need to be made to your chart. Remember, while your PCP puts all their energy into making sure you get and stay healthy, they are responsible for 1000-2000 patients. Only you are in control of your health and the more you understand, the better you can make informed decisions to improve it.