Reading Medical Charts

[somethingpositi]

I'm going to be taking a job at a hospital soon that requires me to read medical charts. My boss has said that he can train me on the job, but that I should also try to look online to see if there are articles or resources that teach people how to read medical charts. I've looked, but I haven't found anything useful. Does anyone have any suggestions of places to look? How do medical students learn to read charts?

Thanks in advance.

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[nick_carraway]

I didn't know that there was a trick to reading charts other than getting used to chicken scratch.

Maybe just familiarize yourself with some of the terms commonly used in the specialty so that it's easier to recognize them when you can only decipher 1 in every 5 letters.

 

[Mobius1985]

Bad handwriting is one problem. Understanding commonly used abbreviations is another hurdle. PERRL=pupils equally round and reactive to light, EOMI=extraoccular movements intact, etc. Charts will be filled with these. Here is a link to a more complete list: http://en.wikipedia.org/wiki/List_of_medical_abbreviations

 

[Percival]

I had a similar job reading medical records and updating them into an electronic system. Wikipedia helps a lot. Plus, don't be afraid to ask the nurses something. Nothing will "prepare" you for it beforehand. You just have to do it and learn as you go, like the doc said.

 

[kypdurron5]

I'm doing some chart reading now... I really don't see how looking this up online would be helpful aside from getting to know some abbreviation's. Nothing will prepare you for bad handwriting- what you can do (and what nurses do) is get familiar with the course of treatment for the types of injuries you're reviewing charts for. That way working through the chicken scratch will be more like multiple choice- there are a limited number of possible orders for any condition. But again, you can't really do that online since every hospital uses a different charting system. When you do start reviewing charts look for the H&P sheets, the admission orders, and maybe the medication lists- but it depends what the purpose of the review is. Also look for links- if you see a CT order, then there will be a CT reading- if you see an admission order then there should be nurses notes, etc. Again, it just depends what you're looking for.