Organizing medical records for readability
September 26, 2012 5:41 PM Subscribe
How can I organize my medical records and lab tests so that they are as easy as possible for a doctor or nurse to navigate?
posted by wireless to Health & Fitness (10 answers total) 2 users marked this as a favorite
I got a rare opportunity to have my medical case reviewed by a team of experts at a hospital. They have requested me to send my medical records and lab tests for them to review. The thing is that I have a ton of records and labs done over the years at different clinics, each with its own format/organization. It seems like it would be a challenge for a clinician to navigate these records and build a clear mental picture. I am motivated to make it as easy as possible for them to grok my records, since they only have limited time to review my case, and I don't want them to get frustrated or miss a relevant result that is buried among the noise. Also, by putting an effort into organizing these records, I want the clinic to see how much this matters to me.
Doctors/nurses: what are some things that make it easier for you to review medical records?
Here are some ideas I have:
- Highlighting the date on each record
- Highlighting abnormal results (e.g. lab results outside of the reference range)
- Writing a little comment on each record or lab result giving context (e.g. "this lab result was from before I started Treatment X")
- Ordering records chronologically or by specialty
- Making an index of my lab tests, so they can easily find all instances of a particular test over the years
(I called the office to ask them directly how they wanted the records organized, but the only person I could speak to was an admin who is not involved in reviewing clinical records.)