Ask Dr. M: What do my doctor’s clinical notes mean?

Question: I have my health records, but I don’t understand a lot of my doctor’s clinical notes. What do all of these abbreviations mean?

Ah, clinical notes. One of the most common forms of health documentation, clinical notes are written or dictated text outlining the interaction a clinician has with you. As you may have already realized by reading your own health records, clinical notes feature a lot of medical abbreviations and shorthand that can leave the average patient puzzled. The reason? Physicians, nurses, allied health providers, etc. all have regulated requirements to document clearly, succinctly, and accurately.

Here are a few of the most common medical abbreviations and acronyms that you’ll see in your clinical notes:

Rx = treatment
HPI = history of presenting illness
c/o = complains of
BP = blood pressure
Pt = patient
Sx = symptoms
HR = heart rate
Hx = history
Dx = diagnosis
PRN = as needed

SBAR

An SBAR note is generally a framework for different members of your healthcare team to communicate. It stands for:

S (Situation)
This is where you tell your clinician what’s going on and why you came to them seeking care. It’s usually brief, and mainly about communicating what is happening.

B (Background)
The goal of the background is to be able to determine what lead you to your current medical status or hospital admission, typically including any information leading up to the Situation. Your doctor will include any details you give them here

A (Assessment/Analysis)
Here your doctor is answering the question of what they believe the problem is, and outline their general assessment of the situation.

R (Recommendation)
This is where your doctor or clinician will suggest what they think needs to be done. This may or may not include a course of treatment (for example, if the Assessment reveals nothing out of the ordinary, the recommendation may be to just wait.)

SOAP

A SOAP note provides a record of a healthcare provider’s encounter with you. These can be used for their own records, or as a form of communication within their team. It stands for:

S (Subjective)
Your clinician’s discussion with you and/or your family, as well as your Chief Complaint (CC) or History of Present Illness (HPI). Essentially, this is the reason for your visit or hospitalization and can be lengthy depending on your experience leading up to the visit.

O (Objective)
Data gathered through observation and measurements, such as vital signs (height, weight, blood pressure, etc.), physical exam, laboratory results, or imaging. This is often based on a head-to-toe assessment, which dictates the general order of subheadings in the note and literally moves from head to toe: general, skin, head, eyes, ears, nose, throat, neck, respiratory, cardiovascular, abdomen/gastrointestinal, extremities, and neurological. The assessment isn’t always complete  —  your provider may choose to only include things that are pertinent to your chief complaint, leaving out things that are irrelevant.

A (Assessment)
Think of the Assessment as a summary of capsule statement that tries to synthesize all of the information that’s been provided down to a few succinct sentences, with the purpose of setting up a diagnosis and plan.

P (Plan)
Here your clinician will outline the next steps to be taken to treat your concern based on the Assessment. This may include procedures, tests, referrals, medical imaging, prescriptions, directions or monitoring.

CAPS

Clinical Assessment Protocols, generally referred to as CAPs, help clinicians focus on key issues identified during the assessment process, so that decisions as to whether and how to intervene can be explored with you.

C (Concern):
The main reason you’re seeing your doctor or clinician, as you describe it.

A (Assessment):
Your clinician’s diagnosis, based on what you told them and any physical symptoms.

P (Plan):
An outline of the next steps and actions to be taken.

S (Supporting Information):
Subjective and objective information based on your interaction with your clinician.

Understanding how clinicians commonly document your visit will not only help you better understand your own health, but will also reveal how your doctor was thinking at the time of documentation, which is a) very cool and interesting and b) your right as a patient! So stop balking in confusion at clinical notes and instead approach them feeling educated and empowered.

Dr. Shaun Mehta is a medical resident and Dot Health’s team physician
shaun@dothealth.ca

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