Your Guide to Decoding Your Medical Records

Benign, malignant, acute, emergent, noncompliant — what do these words mean and when should you be concerned?

When I worked as a registered nurse, part of my job was translating words like this for patients and family members, answering questions and calming fears. But now with patient portals, people can access their medical records and read notes or comments they don't understand or they misinterpret. This can lead to added stress or worry.

"Sometimes patients go for tests in the emergency department and they're able to access their results before I get a chance to see them again," says emergency medicine physician Karin Molander, M.D., in Burlingame, California. "By the time I do see them, they're upset when they might not need to be."

Here's a quick primer on some of the most common confusing terms you might hear in medicine.

For the most part, the English language defines "negative" as something bad and "positive" as good. It's not the same in medicine. If a doctor or other health care provider tells you that your test was positive, it means they found what they were looking for. If they were looking for bacteria in a sample and they found it, the test was positive. If there wasn't any bacteria, it was negative. If they're looking for a blockage in your bowel and they see one on a scan, it's positive. If there isn't a blockage, the scan is negative. So having a positive test usually means there is something wrong.

Of course, like most things in life, there are exceptions. Your doctor might say something like, "I'm seeing good progress with your treatment. It's quite positive." Context is important.

It's not unusual to have false-negatives or false-positives too, especially with some kinds of tests. A good example is if you have COVID-19, but you do the test too early for the virus to register. Your test is negative but you're sick. As you get sicker and do the test again in a few days, it may be positive. You had a false-negative test at first.

Another common word pair that can mix people up is malignant and benign, most often used when talking about cancer. Malignant means a tumor is cancerous; benign means it's not. I used to tell my patients that "B" is better. You want to hear something is benign. That said, a benign tumor can still cause problems. It might have to be removed or your doctor might take a "watch and wait" approach to see if it changes.

"Benign and malignant are also used with other terms as well, such as benign prostatic hyperplasia (BPH), which is an enlarged prostate not related to cancer, and malignant hypertension, which is a severe and sudden spike in blood pressure that can cause organ damage," Molander says. "So again, context is important."

In everyday language, we use "acute" to describe something that is severe or intense, no matter how long it lasts. Chronic means that it's persistent. But in medicine, acute means a condition that happened suddenly, lasts less than six months, and often has an identifiable cause. Examples include a broken leg, appendicitis, an infection or diarrhea that starts just after you ate contaminated food.

Chronic medical issues, on the other hand, are problems that develop over time. This includes conditions like heart disease, arthritis or diabetes. A chronic condition can have one cause or multiple causes, or the cause may never be found. Some, like diabetes and hypertension, likely need long-term treatment or management but others, like chronic kidney disease, might be monitored at first.

You can also have subacute conditions, which fall between acute and chronic. They can last longer than acute conditions but aren't as long-lasting as chronic.

Emergent is urgent — that's where the word emergency comes from. So an emergent situation means it needs to be dealt with as soon as possible. This could be a broken leg where the bones come through the skin, a heart attack or severe bleeding.

Elective is one of those words that makes us think that something isn't necessary however what it really means is that it doesn't have to be done right now. Elective doesn't mean it's frivolous though. Hip replacements due to osteoarthritis and cataract surgeries are elective but needed to improve quality of life. And elective procedures can prevent an emergent situation later down the road. 

"For example, if someone has an abdominal hernia that intermittently causes discomfort, doing an elective surgery to resolve the issue is much safer than an emergent surgery should the hernia become ... trapped in the wrong space," Molander explains. "This can lead to the blood supply of that portion of tissue being cut off, putting the person at risk of an infection and death."

Hearing a medical term that ends in "oma" can sound scary. After all, words like lymphoma, sarcoma and melanoma describe different types of cancer. But not all words that end in "oma" are that serious. For example, a lipoma is a soft painless lump of fat tissue under your skin and a hemangioma is a growth of blood vessels on the skin, often as a birthmark. These are benign conditions. It doesn't mean they don't have to be taken care of, but they're not cancer.

If you've ever accessed your electronic records, you might have found words that made you raise your eyebrows. Or you may have overheard them as health care professionals discuss your case. For example, the words "seems" or "appears" can be offensive if you don't know why they're used.

When I was working night shifts, I'd have to chart in the records if the patients slept. If a patient was sleeping every time I did rounds throughout the night, even snoring, I would write, "Patient appears to have slept all night." Why didn't I write that they did sleep? Because in the morning, when the day staff asked how they slept, it wasn't unusual to hear some say, "I barely slept at all. I tossed and turned all night." What I saw and their experience may not be the same, so I had to write what I saw— that they appeared to be sleeping.

Claims. Doctors will say that a patient claims to have pain or some other symptom when they're taking a medical history. This isn't because they don't believe them, although it may seem like that. They write it because they're reporting what you told them. When health care professionals make notes in your file, they note the subjective things (what you or others tell them) and objective things (what they see for themselves). "If you're seeing a health care professional about a sharp, unrelenting pain in your stomach, they can write that they see you are pale or holding your hand to your abdomen, but they can't write that you have a sharp pain," Molander says. "They have to write that you are reporting it or claiming it."

Denies. This is another word that can make people feel they are being judged or not believed, especially if they see "Patient denies smoking," or "Patient denies alcohol use." But doctors will also write, "Patient denies pain or discomfort." This goes back to the objective reporting. It's concise —faster than writing "patient says she doesn't drink any alcohol" — and it avoids misunderstanding.

Unremarkable. If you've had a medical imaging test, like a CT scan, your doctor may come back and say that they didn't see anything remarkable. "It just means that you didn't find anything unusual on the images that might explain the patient's symptoms or require intervention," Molander explains. There were no abnormal or significant findings. This is good.

Noncompliant. Perhaps one of the terms that bothers people the most is noncompliant. Doctors write it when a patient hasn't followed through with a treatment plan. "This is a term that can be taken the wrong way," Molander says. "When you say a patient is noncompliant for a medication, sometimes the noncompliance is because they can't afford to take their medication, they had a reaction to the new medication or they can't travel for their therapy." Some experts say that the word used should be nonadherent, but even that can sound judgmental.

The medical world is full of words that might not mean what you think they do and many more that you may not understand at all. When you're speaking with your health care provider, ask them to explain what they said if you're unsure. If you read something in your records you don't understand, ask. Misunderstandings can lead to so much more stress and anxiety at an already stressful and anxious time. Open communication can help reduce this.