Patient Information vs Healthcare Provider Information: How Label Differences Affect Care
Nov, 13 2025
When you walk out of a doctor’s office, you might leave with a prescription, a follow-up appointment, and a chart note that says "Type 2 Diabetes Mellitus, E11.9". But inside your head, you’re thinking: "I’m always tired, I’m drinking water nonstop, and I don’t know why I’m losing weight." These aren’t the same things. And that gap? It’s not just a misunderstanding-it’s a safety risk.
Why the Labels Don’t Match
Healthcare providers use standardized codes to document what’s happening with your body. These are called ICD-10 codes for diagnoses and CPT codes for procedures. There are over 70,000 ICD-10 codes. Each one is precise, designed for billing, research, and tracking disease patterns across populations. But these codes were never meant to be read by patients. Patients don’t think in codes. They think in symptoms. "My knees hurt when I walk." "I get dizzy after I eat." "I’m always so tired." These aren’t medical terms-they’re lived experiences. And when providers write "hypertension" in the chart, many patients don’t know that means high blood pressure. A 2019 study found 68% of patients misunderstood common medical terms. Nearly half didn’t know what "hypertension" meant. Over 60% didn’t recognize "colitis." This isn’t about intelligence. It’s about language. Providers are trained to speak in a clinical dialect. Patients speak in the language of their bodies. When those two languages don’t connect, mistakes happen.The Real Cost of Miscommunication
A patient reads "poorly controlled DM" in their portal and thinks, "I’m a bad diabetic." They feel blamed. They don’t ask questions. They skip refills. A 2022 survey by the American Medical Association found that 57% of patients felt confused by the terms in their medical records. Of those, 32% avoided follow-up care because of it. Doctors aren’t immune to the problem either. In a 2023 Medscape survey, 64% of physicians said they spent 15 to 30 minutes per visit just explaining terms. That’s a third of a typical 15.7-minute appointment-time that could’ve been used for treatment planning, emotional support, or answering real concerns. The Institute of Medicine estimated back in 2001 that communication failures contributed to 80% of serious medical errors. That number hasn’t gone down. In fact, with more patients accessing their records through portals like MyChart, the risk is growing. If your chart says "metformin 500mg BID," and you don’t know what "BID" means, you might take it once a day-or twice at once.Who’s Trying to Fix This?
It’s not just patients and doctors. A whole system is trying to bridge this gap. Health Information Management (HIM) professionals are the hidden middlemen. They’re the ones who translate clinical notes into coded data for billing, but also ensure those records are accurate and private under HIPAA. They train for over 1,200 hours in medical coding, transcription, and patient communication. Their job? Make sure the system works-for providers, for insurers, and for you. Some hospitals are taking bold steps. Kaiser Permanente started letting patients read their doctors’ notes back in 2010. They called it OpenNotes. Since then, they’ve seen a 27% drop in patient confusion about diagnoses and a 19% increase in medication adherence. That’s not magic. That’s transparency. Mayo Clinic built EHR templates that auto-translate clinical jargon. "Myocardial infarction" becomes "heart attack." "Chronic obstructive pulmonary disease" becomes "lung disease from smoking." In their pilot, patient confusion dropped by 38%. The government is pushing too. The 21st Century Cures Act of 2016 forced providers to give patients full access to their clinical notes by 2021. No more hiding behind legalese. If your doctor wrote "depression with anxiety," you now get to read it-and ask, "What does that mean?"
What’s Changing Now?
The world of medical coding is evolving. The World Health Organization’s ICD-11, rolled out globally in 2022, now includes plain-language descriptions alongside each code. For the first time, a diagnosis code comes with a human-readable explanation. New tech standards like HL7 FHIR let systems show both the clinical term and the patient-friendly version at the same time. So a provider sees "E11.9" while you see "Type 2 Diabetes." Same data. Different language. And AI is stepping in. Google’s Med-PaLM 2, released in 2023, can convert clinical notes into plain language with 72% accuracy. It’s not perfect yet-clinical systems need 95% accuracy to be trusted-but it’s a start. The American Medical Informatics Association predicts that by 2027, 60% of electronic health records will have real-time translation built in. That means your doctor types "hyperlipidemia," and your phone shows "high cholesterol." No translation needed.What You Can Do Right Now
You don’t have to wait for technology to fix this. You can start today.- Ask: "Can you say that in plain language?" No shame in it. Providers expect it.
- Use the "teach-back" method: After your doctor explains something, say, "So, just to make sure I got it-you’re saying I need to take this pill twice a day with food because it helps lower my sugar?" If you can repeat it back, you understand it.
- Read your records. If something doesn’t make sense, write it down. Bring it to your next visit.
- Don’t Google symptoms without context. Medical terms can scare you. "Ataxia" sounds like a disease. It’s just trouble with balance.
- Ask for a printed summary. Many clinics now offer one after visits. It’s not a bill-it’s a summary of what was discussed.
What Providers Need to Do
Providers aren’t the enemy. Most want to communicate better. But the system doesn’t make it easy.- Use plain language in notes-even if the system forces you to code something as "E11.9," write "Type 2 Diabetes" in the clinical narrative.
- Don’t assume patients know what "BID" or "PRN" means. Spell it out: "twice a day" or "as needed."
- Use visual aids. A picture of a pill bottle with "take with breakfast" written on it sticks better than a prescription label.
- Normalize asking: "What’s your biggest worry about this condition?" That opens the door to real conversation.
The Bigger Picture
This isn’t just about words. It’s about power. For decades, medical records were locked away-written in a language only insiders understood. That kept control in the hands of providers. But now, patients have access. And they’re using it. The shift from provider-centered care to patient-centered care isn’t just a buzzword. It’s a legal requirement, a reimbursement incentive, and a moral imperative. CMS now ties 2% of hospital payments to how well patients say they understood their care. That’s not small change. That’s real pressure to improve. The goal isn’t to eliminate medical terminology. It’s to make sure patients aren’t left behind by it. Medicine needs codes for research, billing, and safety. But it also needs clarity for healing.Final Thought
Your body speaks in symptoms. Your provider speaks in codes. The best care happens when those two voices are heard equally. You don’t need a medical degree to understand your health. You just need someone willing to translate.Why do doctors use medical terms instead of plain language?
Doctors use medical terms because they’re part of a standardized system used for billing, research, and legal records. Codes like ICD-10 and CPT ensure consistency across hospitals and insurers. But that doesn’t mean they should be used when talking to patients. Many providers now use plain language in notes meant for patients, especially since laws now require patients to see their records.
Can I ask my doctor to rewrite my medical records in simpler terms?
You can’t rewrite your official medical record, but you can ask for a plain-language summary. Many clinics now offer this. You can also request that your provider explain terms as they write them. If your doctor uses a term you don’t know, say, "Can you explain that in a different way?" Most will be happy to help.
What’s the difference between ICD-10 and patient-friendly labels?
ICD-10 is a coding system used by healthcare systems to classify diseases for billing and statistics. Each code (like E11.9 for Type 2 Diabetes) is precise and universal. Patient-friendly labels are plain-language descriptions-like "Type 2 Diabetes" or "high blood pressure"-that help you understand what’s going on. Some newer systems now show both side by side.
Why do I get confused reading my medical records?
Medical records are written for providers, not patients. They include abbreviations, jargon, and codes meant for internal use. Terms like "DM," "HTN," or "COPD" are common in charts but rarely explained. A 2022 survey found 57% of patients felt confused by these terms. That’s why initiatives like OpenNotes and plain-language EHR templates are growing.
How can I make sure I understand my diagnosis?
Ask three things: 1) What is this condition called in plain language? 2) What does it mean for my daily life? 3) What are the next steps? Use the teach-back method: repeat what you heard in your own words. If you’re still unsure, ask for a handout or a video explanation. Many hospitals now offer these resources.
Is it safe to rely on AI tools to translate my medical notes?
AI tools like Google’s Med-PaLM 2 can help explain complex terms, but they’re not perfect yet. They’re about 72% accurate, which is good for learning but not for making medical decisions. Always confirm what the AI says with your provider. Use AI as a helper, not a replacement for talking to your doctor.
Eleanora Keene
November 14, 2025 AT 10:55So many people don’t realize how much power is in simple words. I had a doctor tell me I had 'HTN' and I thought it was some new drug. Turns out it’s just high blood pressure. I felt stupid, but honestly? It’s not my fault they didn’t explain it. I started asking 'Can you say that in English?' after that. No more shame. It’s my body, my health.
And honestly? If your chart says 'DM' and I don’t know what that means, that’s on you, not me. We’re not all med students. We’re just trying to survive.
Thanks for saying this out loud. I’ve been waiting for someone to call this out.
Joe Goodrow
November 15, 2025 AT 05:23Let me guess-this is one of those woke medical reform pieces. You want doctors to dumb down their language so people can feel better about being unhealthy? We’ve got 70,000 codes for a reason. Precision matters. If you can’t handle a little Latin and Greek, maybe don’t go to the doctor. Or better yet, stop eating junk and quit smoking. Problem solved.
Stop coddling people. Medicine isn’t a therapy session.
Don Ablett
November 16, 2025 AT 21:16The structural tension between clinical precision and patient comprehension is a well-documented phenomenon in health informatics literature. The ICD-10 system was designed for interoperability and statistical aggregation, not patient education. While plain-language translations may improve adherence, they introduce ambiguity in longitudinal data tracking. The trade-off is nontrivial.
That said, dual-display systems like FHIR’s extension for human-readable content represent a pragmatic compromise. The real challenge lies in standardizing translation protocols across EHR vendors. Without uniformity, we risk fragmentation.
Also, 'BID' is not jargon-it’s Latin. And it’s universally understood in clinical contexts. Replacing it with 'twice daily' may help patients, but it dilutes the professional lexicon.
gent wood
November 18, 2025 AT 18:13I’ve been in this game for 22 years, and I’ve seen this exact problem grow worse. I used to sit with patients for 10 minutes just to explain what 'hyperlipidemia' meant. Now? They’re reading their own charts and coming in with questions that make no sense because they googled 'E11.9' and got 47 scary articles.
But here’s the thing-when we take the time to translate, when we don’t rush, when we say 'Let me say that again in a way that sticks'-it changes everything. My patients’ A1Cs dropped. They showed up for follow-ups. They stopped skipping meds.
This isn’t about dumbing down. It’s about bridging. And it’s worth every extra minute.
Also, if your doctor uses 'COPD' without explaining, fire them. No excuses.
Jane Johnson
November 19, 2025 AT 23:19This is exactly why I stopped trusting doctors. They write things like 'poorly controlled DM' like it’s a personal failure. I’m not lazy. I work two jobs and my insurance won’t cover the glucose monitor. But sure, let me blame myself for being 'noncompliant.'
And now you want me to read my own records? Great. Let me just enjoy the emotional toll of being told I have 'anxiety with depression' in bold letters while my kids scream in the waiting room.
It’s not the language. It’s the system. And you’re just rearranging deck chairs.
Peter Aultman
November 21, 2025 AT 10:57Man I’ve been there. Got my records and saw 'metformin 500mg BID' and thought BID was some kind of new supplement. Turned out it meant twice a day. I almost didn’t take it for a week cause I thought I was overdosing.
Now I just ask 'what’s this mean in normal talk?' and they’re cool with it. Honestly most docs are just busy, not mean. But yeah, the system’s broken. We need plain language built in. No more guessing.
Also, if your doc uses 'HTN' - just say 'high blood pressure?' They won’t be mad. They’ll be relieved you asked.
Sean Hwang
November 21, 2025 AT 18:56My grandma couldn’t read her records. Said 'all them letters made her head spin.' So I started writing down what the doctor said in big letters on a sticky note. 'Diabetes = sugar problem. Pill = keep sugar low. Don’t skip.' She got it. She lived longer.
Doctors don’t need to stop using codes. They just need to say the words out loud too. Simple. No fancy tech needed. Just care.
And if you’re scared to ask? Do it anyway. They’ve heard it a thousand times. You’re not being annoying. You’re being smart.
Barry Sanders
November 23, 2025 AT 16:22Wow. Another article about how patients are too dumb to understand medicine. Congrats, you’ve discovered that people are bad at reading. Newsflash: not everyone’s a doctor. Shocking.
Let’s just make all medicine a TikTok video. 'High blood pressure? Here’s a dance.'
Next you’ll want to replace stethoscopes with emojis.
Chris Ashley
November 24, 2025 AT 21:52My doctor told me I had 'COPD' and I didn’t know what it meant. So I asked. He looked at me like I was from another planet. Then he said, 'It’s lung disease from smoking.' I said, 'Oh, so I’m being blamed for smoking?' He didn’t answer.
Now I just Google everything. And yeah, I’m scared. But at least I’m not the one being lied to by a chart full of hieroglyphs.
Brittany C
November 26, 2025 AT 08:28As someone who works in medical coding, I can tell you this: we don’t write for patients. We write for CMS, for audits, for compliance. The ICD-10 code is sacred. The narrative? Optional. That’s why OpenNotes is revolutionary-it forces the narrative to matter.
But here’s the catch: if you want plain language, you need to pay for it. Most clinics don’t have the staff to translate. And if you’re on Medicaid? Good luck getting a summary.
So yes, the tech is coming. But equity? Still broken.
Sean Evans
November 27, 2025 AT 20:09AI translating medical notes? 😂😂😂
Let me guess-next you’ll say we should let TikTok doctors diagnose cancer. 'Hey Siri, is this a heart attack?'
72% accuracy? That’s a death sentence waiting to happen. You think your grandma’s gonna trust an algorithm more than her doctor? She’ll die because Google said 'it’s probably just indigestion.'
And don’t even get me started on 'patient-friendly labels.' So now we’re sanitizing reality? 'Heart attack' sounds scary? Fine. Let’s call it 'chest discomfort event 2.0.'
Stop pretending medicine is a customer service experience. People die when you water this down.