Cracking the Code: A quick reference guide to interpreting patient medical notes

Introduction

In the secondary care setting, health professionals, other than doctors, have been actively involved in extracting and interpreting information found within patient medical notes for many years. Cracking the Code was originally developed as a tool for use by MPharm students to find their way through the seemingly foreign language of medical notes. It has since been expanded to include explanations of how many common medical examinations and tests are performed and how the results of these should be interpreted.

Cracking the Code covers the basics of the contents of patients’ medical notes, from a review of physiological systems to the interpretation of tests and investigations commonly ordered for patients. Common medical terminology used in a review of physiological systems is briefly explained. Commonly encountered investigative procedures are defined and their use explained. Medical laboratory tests are similarly explored.

Much of this book concentrates upon the secondary care environment because this remains the main setting in which healthcare professionals have free and open access to patient medical notes. However the expanding roles of healthcare professionals in the primary care sector, such as pharmacists working within GP practices, and non-medical prescribers in nursing, pharmacy and physiotherapy, mean that all practitioners need to be able to unlock the code. It is hoped that this book will therefore be of use not only to the undergraduate pharmacy students for whom it was originally developed, but also to pre-registration trainees and pharmacists practising in all sectors of the profession, and all other healthcare professionals who access patient medical notes on a routine basis.

This second edition has been updated to incorporate measurements of body weight and surface area, capillary blood gases, sepsis screening, common drug serum levels, and changes to the reporting of cardiac troponins. This book is not designed to be a comprehensive text to be read from cover to cover. Rather, it is a quick reference guide to dip in and out of, as the need arises. Many other, larger, texts are available, which explain in great detail all the areas covered in this book, should a deeper exploration be required.

Katie Maddock, December 2017

Section 1

Medical terminology

In order to interpret a patient’s medical notes accurately and with confidence, it is essential to have a good grasp of medical terminology. Some of the terms that are commonly encountered may appear to be very long and complicated but they are generally built up from smaller ‘building blocks’. Once the longer terms have been broken down into their constituent blocks, the meaning becomes much clearer.

Medical terms have three basic components: the root, which forms the basis of the word; a prefix – any syllables added in front of the root to modify it and a suffix – any syllables added after the root to modify it. Knowledge of the meanings of a few common roots, prefixes and suffixes enables the understanding of the majority of commonly encountered medical terms.

For example:

i.e. a condition resembling underactivity of the parathyroid glands.

Tables 1.1 and 1.2, on page 2, contain some of the common roots, prefixes and suffixes that are encountered in clinical practice.

Table 1.1: Common medical prefixes, suffixes and roots

Table 1.2: Common surgical suffixes

Section 2

Patient medical notes

To be involved effectively in the clinical decision-making process, it is important to be able to understand and utilise the information to be found in the patient medical notes. On occasions it is also necessary for the pharmacist to record their interventions in a patient’s medical notes.

The medical notes are a chronological record of all significant aspects, including drug treatment, of a patient’s care. These are completed for both inpatient stays and for outpatient clinic visits. As a clinical pharmacist you will frequently intervene directly in the care of patients to ensure the safety and efficacy of their treatment. If you do need to intervene in a patient’s drug treatment, there are a number of ways in which you can convey this information to the prescriber(s) concerned.

Face to face with the prescriber

This is much the best way to deal with any concerns you have. The modifications you wish to recommend to the prescriber can be discussed and you will all have the information you require to hand. The prescriber is unlikely to document your intervention in the patient’s medical notes.

Bleeping or phoning the doctor

If the prescriber is not available for a face to face discussion and the intervention you wish to make is urgent, this is the method used for contacting the prescriber. However, it may not be a convenient time for the prescriber to talk to you. Again, it is unlikely that the prescriber will document your intervention in the patient’s medical notes.

Leaving a note on the prescription

This is often used as a method of communication in the hospital environment, particularly if the prescriber is a surgeon, is in theatre and cannot be disturbed. However, such notes are easily lost and if your intervention is not addressed by the prescriber it is difficult to say whether the prescriber saw your note and chose to ignore it, or whether your note was seen at all. Again there is no permanent record of your intervention.

Leaving a message with another member of staff

Your message may not be passed on correctly, if at all. Again there is no permanent record of your intervention.

The following are examples of when you, as a clinical pharmacist, should document your interventions in a patient’s medical notes:

•When you recommend that a drug is initiated or discontinued

•When you have discovered that an adverse drug reaction has occurred

•When you discover that the patient is not, or has not been, compliant with their medication

•When your input has been requested by the medical team

•When a critical change to a dosage regimen has occurred

•When an important recommendation has not been followed

•When your written communication would facilitate a