Medical health records form an essential part of a patient’s present and future health care.

So it is important we all should know the basics of how to read a medical report.

In this blog, Karetrip will give you some pointers on how to read and analyze your medical reports.

Importance of Medical Health Records

Medical health records are a vital component of a patient's healthcare, serving multiple purposes:

• Patient Care: Essential information for present and ongoing care

• Healthcare Management: Used in facility management and planning

• Research and Statistics: Supports medical research and health statistics production

Purpose of Medical Records

The primary purpose of medical records is to:

1. Document facts about a patient's health during their current admission or attendance

2. Support continuing care for future healthcare needs

3. Consolidate medical reports at one place

4. Prevent missed or duplicate tests etc.

Essential Information in Medical Records

A patient's medical record should accurately provide:

1. Patient Identification: Who the patient is and who provided healthcare

2. Care and Treatment Details: What, when, why, and how services were provided

3. Outcome of Care: The results of care and treatment

Common Sections in Medical Reports

1. Patient Information

• Name

• Age

• Gender

• Hospital identification number

• Address

• Phone number

• Emergency contact information

2. Clinical History

• Symptoms

• Past medical history

• Reason for test/examination

• Allergies

3. Examination Findings

• Physical examination results

• Vital signs (e.g., blood pressure, heart rate)

4. Investigations Ordered

• List of tests ordered (e.g., blood tests, X-rays, MRI)

5. Test Results

• Detailed findings from investigations

• Normal reference ranges

6. Diagnosis

• Doctor's conclusion based on findings

7. Treatment Plan

• Recommendations for treatment

• Medications

• Lifestyle changes

• Further tests

8. Follow-up

• Instructions for future visits or tests.

Understanding Common Blood Tests

Blood testing, also known as blood analysis, is a laboratory examination of the blood in your body. It's typically ordered by healthcare professionals to:

• Monitor treatment progress

• Manage health conditions like high cholesterol, diabetes, or illness

• Conduct routine check-ups

Blood tests provide valuable insights into your overall health, helping doctors diagnose, treat, and prevent various medical conditions. Let's explore some common blood tests and what they reveal about your health.

Common Blood Tests

1. Complete Blood Count (CBC)

• Measures 10 components, including red and white blood cells, platelets, and hemoglobin

• Abnormalities can indicate nutritional deficiencies, anemia, blood cancer, infections, or clotting problems

2. Basic Metabolic Panel (BMP)

• Measures 8 components, including glucose, calcium, and electrolytes

• Abnormal results may indicate diabetes, kidney disease, or hormone imbalance

3. Comprehensive Metabolic Panel (CMP)

• Measures all BMP components, plus additional ones like protein and liver enzymes

• Abnormalities can indicate various health issues, depending on the component

4. Lipid Panel

• Measures HDL (good) and LDL (bad) cholesterol levels

• Abnormal levels can indicate heart disease risk

5. Thyroid Panel

• Measures thyroid hormone levels, including TSH, T4, and T3

• Abnormal levels can indicate thyroid disorders or hormone imbalances

6. Cardiac Biomarkers

• Measures enzyme levels, including creatine kinase and troponin

• Abnormal levels can indicate heart damage or disease

7. Sexually Transmitted Infection (STI) Tests

• Diagnoses STIs like HIV, syphilis, and chlamydia through blood tests

8. Coagulation Panel

• Measures blood clotting time and effectiveness

• Abnormal results can indicate hemophilia, liver disease, or vitamin deficiency

9. Electrolyte Panel

• Measures mineral levels, including magnesium and potassium

• Abnormal levels can indicate kidney, lung, or heart problems

10. Allergy Testing

• Measures IgE levels to detect allergies

11. Autoimmune Disease Tests

• Measures various components to detect autoimmune diseases like rheumatoid arthritis or lupus

Understanding Imaging Tests

Imaging tests help your doctor diagnose and treat medical conditions by creating pictures of the inside of your body. These tests can reveal injuries, diseases, and other health issues, allowing for timely and effective treatment. Here are some common types of imaging tests:

Types of Imaging Tests

X-ray: Uses low-level radiation to create images of bones, lungs, and other internal structures

Ultrasound: Uses high-frequency sound waves to create images of internal organs and tissues

MRI (Magnetic Resonance Imaging): Uses magnetic fields and radio waves to create detailed images of internal structures

CT (Computed Tomography) Scan: Uses X-rays and computer technology to create detailed cross-sectional images of internal structures.

Common Sections under Imaging Tests/ Radiology Reports

1. Type of Exam

• Date, time, and type of exam (e.g., CT scan of the abdomen and pelvis)

2. History/Reason for Exam

• Information about your symptoms and medical history

3. Comparison/Priors

• Comparison with previous exams (if available)

4. Technique

• Description of how the exam was performed (mainly for documentation purposes)

5. Findings

• List of observations for each area of the body examined

• Normal, abnormal, or potentially abnormal findings

6. Impression

• Summary of findings and possible causes (differential diagnosis)

• Recommendations for further testing or follow-up

Additional Information

• The radiologist signs and sends the report to your physician

• Your doctor discusses the results with you

• You can contact the imaging staff or radiologist if you have questions

Interpreting Results

• Reference Range: Most tests come with a “reference range,” which indicates what is considered normal. Your results will be compared to these ranges.

• Units of Measurement: Results may be reported in various units (e.g., mg/dL for glucose, g/dL for hemoglobin). Understanding these units is important for interpretation.

• Abnormal Results: If a result falls outside the reference range, it could indicate an underlying issue, but further tests or a doctor’s interpretation are necessary.

Common Medical Terms and Abbreviations

BP: Blood Pressure

HR: Heart Rate

BPM: Beats Per Minute

CBC: Complete Blood Count

LFT: Liver Function Test

KFT: Kidney Function Test

USG: Ultrasound

CT: Computed Tomography

MRI: Magnetic Resonance Imaging

IV: Intravenous

Rx: Prescription

Understanding Prescription

The prescription on medical reports contains dosage, frequency and duration of the medicines.

There are some medical abbreviations for frequency of the medicines which includes:

OD: Once daily

BD: Twice a day

TDS: Three times a day

QID: Four times a day

SOS: If required/as required

STAT: Single dose

Route of Administration: The way medication is given to the body

• PO (Oral): Taken by mouth

• IM (Intramuscular): Injected into a muscle

• IV (Intravenous): Injected into a vein

Form of Medication

• Tab: Tablet

• Cap: Capsule

• Inj: Injection

• Syp: Syrup

• gtt: Drops (e.g., eye drops or ear drops)

Understanding medical reports and asking questions lets you be more involved in your healthcare. Familiarize yourself with the basics to discuss your reports with professionals and make informed decisions. Always consult your doctor to understand your reports and treatment plans, and to address any questions.

The information provided represents the views and opinions of Karetrip. It is crucial to conduct your own independent research before making any decisions regarding your healthcare journey. - Disclaimer