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Learn how to read and understand your medical records. Decode lab results, interpret medical terminology, understand diagnosis codes, and identify errors in your health records.
A complete guide to understanding lab results, decoding medical terminology, and making sense of your health data
Your medical records contain valuable information about your health, but they can be difficult to understand. Written in medical shorthand and filled with codes, abbreviations, and clinical terminology, these documents can feel like they're written in a foreign language.
This guide will teach you how to read and understand your medical records, including how to interpret lab results, decode common medical abbreviations, understand diagnosis codes, and identify potential errors that need correction.
Before diving into the details, it helps to understand the different types of documents you may encounter in your medical records:
Documentation of your visits with healthcare providers. Includes the reason for your visit, examination findings, diagnosis, and treatment plan. Usually follows the SOAP format: Subjective, Objective, Assessment, Plan.
Results from blood tests, urine tests, and other laboratory analyses. Shows your values compared to normal reference ranges.
Written interpretations of X-rays, CT scans, MRIs, and ultrasounds by radiologists. Includes findings and impressions.
Detailed summaries created when you leave a hospital. Includes admission diagnosis, procedures performed, medications, and follow-up instructions.
Detailed accounts of surgical procedures, including technique used, findings during surgery, and any complications.
Reports from specialists who were asked to evaluate your condition and provide recommendations.
Lab results are among the most common and confusing parts of medical records. Here's how to interpret them:
Every lab test includes a "reference range" or "normal range." Your result will be compared to this range. Values outside the range are typically flagged:
| Test | Normal Range | What It Measures |
|---|---|---|
| Hemoglobin (Hgb) | Men: 13.5-17.5 g/dL, Women: 12.0-16.0 g/dL | Oxygen-carrying protein in red blood cells |
| White Blood Cells (WBC) | 4,500-11,000 cells/mcL | Immune system cells; high may indicate infection |
| Platelets | 150,000-400,000/mcL | Blood clotting cells |
| Glucose (Fasting) | 70-100 mg/dL | Blood sugar level |
| HbA1c | Below 5.7% | 3-month average blood sugar |
| Creatinine | 0.7-1.3 mg/dL | Kidney function marker |
| BUN | 7-20 mg/dL | Blood Urea Nitrogen; kidney function |
| Total Cholesterol | Below 200 mg/dL | Blood fat levels |
| LDL Cholesterol | Below 100 mg/dL | "Bad" cholesterol |
| HDL Cholesterol | Above 60 mg/dL | "Good" cholesterol |
| Triglycerides | Below 150 mg/dL | Blood fat from food |
| TSH | 0.4-4.0 mIU/L | Thyroid function |
| ALT | 7-56 U/L | Liver enzyme |
| AST | 10-40 U/L | Liver/heart enzyme |
A single abnormal lab value doesn't necessarily indicate a problem. Many factors can affect results, including what you ate, medications you take, and even stress. Always discuss abnormal results with your healthcare provider before drawing conclusions.
Medical records are filled with abbreviations that save time for healthcare providers but can be confusing for patients. Here are the most common ones you'll encounter:
Many medical terms are built from Greek and Latin roots. Understanding these building blocks can help you decode unfamiliar terms:
Your medical records contain standardized codes that describe your diagnoses and the procedures performed. These codes are used for billing, but they're also valuable for understanding your health history.
The International Classification of Diseases, 10th Revision (ICD-10) codes describe your diagnoses. They follow a specific format: a letter followed by numbers (e.g., J06.9).
Example ICD-10 Codes:
Current Procedural Terminology (CPT) codes are 5-digit numbers that describe medical procedures and services performed.
Example CPT Codes:
You can search for any ICD-10 or CPT code online to understand exactly what it means. Websites like the CDC's ICD-10 browser and the AMA's CPT lookup tool provide detailed descriptions.
Medical record errors are more common than you might think. Studies suggest that up to 70% of medical records contain at least one error. Here's what to look for:
Wrong name spelling, incorrect date of birth, wrong gender, incorrect address, or mixed up with another patient.
Conditions listed that you don't have, diagnoses you were never told about, or outdated diagnoses that have been resolved.
Wrong medications listed, incorrect dosages, medications you're allergic to not flagged, or discontinued medications still showing as active.
Drug allergies or other allergies not documented, or allergies listed that you don't actually have.
Wrong family history, incorrect surgical history, or symptoms documented that you didn't report.
Vital signs are measurements of your body's most basic functions. Here's what normal ranges look like for adults:
<120/80 mmHg
Normal blood pressure. First number (systolic) measures pressure during heartbeat; second (diastolic) measures pressure between beats.
60-100 bpm
Normal resting heart rate. Athletes may have lower rates. Rate increases with exercise, stress, or illness.
97.8-99.1°F (36.5-37.3°C)
Normal body temperature range. Above 100.4°F (38°C) is generally considered a fever.
12-20 breaths/min
Normal breathing rate at rest. Higher rates may indicate respiratory distress or other conditions.
95-100%
Percentage of oxygen in your blood. Below 95% may warrant medical attention.
18.5-24.9
Normal weight range. Calculated from height and weight. Below 18.5 is underweight; 25+ is overweight.
Common abbreviations include: BP (blood pressure), HR (heart rate), Dx (diagnosis), Rx (prescription), PRN (as needed), BID (twice daily), TID (three times daily), NPO (nothing by mouth), and WNL (within normal limits). Our medical abbreviations dictionary has 200+ common terms explained.
Lab results include reference ranges showing normal values. Results flagged with H (high) or L (low) are outside normal range. However, slightly abnormal values aren't always concerning—discuss with your doctor. Common tests include CBC (complete blood count), BMP (basic metabolic panel), and lipid panels.
ICD-10 codes are standardized diagnosis codes used worldwide. They follow a format of a letter plus numbers (like J06.9 for upper respiratory infection). These codes are used for billing, research, and tracking your health conditions across providers.
CPT (Current Procedural Terminology) codes are 5-digit numbers that describe medical procedures and services. For example, 99213 is a standard office visit, and 85025 is a complete blood count test. These codes determine how much you're billed for services.
Look for: wrong personal information, diagnoses you don't have, incorrect medications or dosages, missing allergies, and inaccurate medical history. Studies show up to 70% of records contain at least one error. Under HIPAA, you have the right to request corrections.
SOAP stands for Subjective (your symptoms in your words), Objective (exam findings and test results), Assessment (the doctor's diagnosis), and Plan (treatment plan). Most progress notes follow this format to organize clinical information in a standardized way.
Normal adult vital signs: Blood pressure under 120/80 mmHg, heart rate 60-100 bpm, temperature 97.8-99.1°F, respiratory rate 12-20 breaths/min, and oxygen saturation 95-100%. Values outside these ranges may indicate health concerns worth discussing with your provider.
Yes, under HIPAA you have the right to obtain copies of your medical records from any healthcare provider. You can request records through patient portals, by mail, or in person. Providers must respond within 30 days and can only charge reasonable fees.
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Now that you know how to read them, make sure you have copies of all your important health records. We can help you request records from any healthcare provider.