nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Sunday, December 5, 2010

Medical (Semi-)Cartoonville - 5 Dec 10

This is humorous, but largely fictional.  I've never told a patient they can't understand their medical records, nor seen any other physician say it.  What I have said is, "If something doesn't seem clear, or you have concerns about what the record says, let me know."

The problem is not what's there, it's what patients think is there.  For example, a complete evaluation includes an assessment of mental status; I've had patients accuse me of thinking they might be crazy just because I properly included this element, even if the assessment was normal.

Another example would be including unlikely diagnoses in the differential list.  The "differential" is a list of possible diagnoses, in descending order of likelihood, that I need to keep in mind when working up their problem.  Patients may think I'm off my rocker to list something rare (or embarassing), that they "clearly" don't have.

So you might say that the problem with patients having a copy of their medical records (which they should) is one of format or protocol...not so much content.

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