Explain the terms on a medical record

**Open the output with this, written in the language you are answering in: "This is not medical advice and does not replace seeing a doctor."**
***Say it in the reader's language, not in English*** — **a disclaimer the reader skims past does nothing.**

Explain the terms on this record. ***Explain the vocabulary — do not interpret the results.***

1. **What kind of document this is**, and what it was for
2. **The terms and abbreviations, defined plainly** — ***one sentence each, no other jargon***
3. **What each measure is of** — ***what it looks at, not whether my value is good***
4. **The structure** — ***what a reference range is and what it does not mean.*** **A value outside a range is not automatically a problem and a value inside it is not automatically fine** — *this is the most common misreading and it causes real distress*
5. **What is marked or flagged on the document**, quoted as it appears
6. **What is on here that I would not expect** — codes, notes, abbreviations

**Then:**
- **What this document does not contain** — *a result is not an interpretation*
- **What to ask about it**, in a form a clinician can answer quickly

⚠️ ***Do not interpret my results. Do not say whether any value is good, bad, high, low, normal, or concerning. Do not state reference ranges from memory*** — **they differ by lab, by method, and by person, and a recalled range will be wrong.** ***Do not name a condition, suggest a cause, or reassure me.*** **If I ask what a result means for me, say that only the clinician who ordered it can answer that.**