A medical report is a text written by a doctor about a patient’s care process, describing processes, tests, and observations in order to arrive at a proper diagnosis and treatment. Reports are excerpts from a person’s biography in which doctors describe their health. They also allow for the development of clinical and epidemiological studies, and the management and evaluation of care. They are also legal documents that take on great importance in legal proceedings. Although sometimes some professionals perceive them as a routine obligation, medical reports are the testimonial column of the health system in the sense that they shape the historical traces of the centers.
Rosa Estopà, researcher at the IULATERM Institute of Applied Linguistics at Pompeu Fabra University, coordinates The Medical Report: how to improve its wording to make it easier to understand, a new Notebook by the Dr. Antoni Esteve Foundation who offers tools and resources to write more understandable medical reports. Its aim is to make professionals aware of the main aspects of using a language that can be an obstacle to understanding medical reports. “If the horizon in the field of health is to work for a collaborative medicine that involves dialogue with the patient and transmission of understanding messages, the language – and the communicative and editorial aspects – must be part of the training. in medicine ”, stresses Estopà.
So it’s a linguistic look at the medical report. If professionals are aware of mistakes and misuse of language and follow basic recommendations for clear, clear writing, medical reports may be more understandable, not only for patients but also for other professionals and treatment programs. and information retrieval.
With this premise, the book is structured in seven chapters. Each of them deals with a key aspect of writing medical reports. Each topic provides a general introduction to the phenomenon, examples of excerpts from actual medical reports, recommendations and concrete advice, real practical cases with solutions to the proposed cases and bibliography. The book offers many examples and exercises from real medical reports from various hospitals that have been anonymized.
In the first chapter, Elisabet Llopart-Saumell, from the University of Alicante, and Iria da Cunha, from the Universidad Nacional de Educación a Distancia, talk about the textual aspects of the medical report. The second chapter develops the topic of the real understanding of medical reports by patients. It is signed by Ona Domènech-Bagaria, from the Universitat Oberta de Catalunya; Laia Vidal-Sabanés, from Pompeu Fabra University and Rosa Estopà herself. In the third chapter, Estopà and M. Amor Montané, from the Institut d’Estudis Catalans, address the terminology used in medical reports.
The fourth chapter is dedicated to abbreviations, whether abbreviations, acronyms or symbols and is developed by Jorge M. Porras-Garzón, from Pompeu Fabra University, and Vidal-Sabanés. The fifth chapter, by Mercè Lorente, from the Institute of Applied Linguistics, and Òscar Pozuelo, a researcher in the IULATERM group, focuses on the syntactic aspects of the reports. Signed by Elisabet Llopart-Saumell and Yingfeng Xu of ESIC Business & Marketing School, the sixth chapter addresses pragmatic aspects such as connectors and personal treatment used in reports to refer to the patient. Finally, Jorge Vivaldi, also a researcher at IULATERM, deals with orthotypographic errors and their consequences in the last chapter.
“The suspicion that doctors use cryptic language, often unnecessarily technical, is still well-founded,” says Josep-Eladi Baños, rector of the University of Vic – Central University of Catalonia. Frequently, terms used in common language have completely different meanings, and the use of neologisms is a common practice. This is of relative importance when the affected person is not involved in the actions of other professionals, but it is a completely different issue when we talk about medical language. Thus, swelling of the ankles is called malleolar edema, heartburn is called heartburn and sore throat when swallowing, odynophagia. Any enlightened person may have difficulty understanding when told about paresthesias, anasarca, sarcopenia, seizure crisis, or pollaciuria. In order to be precise, the use of terms that are incomprehensible to the general population is often excessive and sometimes clearly unnecessary, ”concludes Baños.