Medical records and test results

By Dr Samantha Line, Clinical Lead, Cowley Road Medical Practice

Please note: The word “clinician” is used here. Clinicians include doctors, nurses, pharmacists, physicians’ associates (PAs), healthcare assistants (HCAs) and other professionals who write in medical notes. Non-clinical staff such as receptionists and administrators also write in medical notes. 

Understanding your test results

What kind of results are included in my notes?

The most common test results are laboratory tests (such as blood, urine and stool tests, tests for infections, and cervical smear results) and imaging (such as x-rays or ultrasound scans).

Only results of tests which have been requested by the GP surgery are included in your notes.

What results are not included in my notes?

Tests which have been requested by other clinicians (including hospital doctors) are not recorded in your notes. This includes blood tests where you have brought a hospital blood card to the surgery, and any imaging (scans) requested by a hospital.

How long will my test results take to come back?

This varies with the type of test. Many blood results are available within 24 hours, but it may take longer for your clinician to review, act on, and release the results. Some more specialised tests may take days or weeks to come back.

Scan results can take longer to be available. X-rays have to be reported by a radiologist before they are sent to us, and this may take days or weeks. Ultrasound scan results are usually available within days.  

What should I do after I have tests?

All results are reviewed by a clinician, who will usually contact you or ask you to book an appointment if they are concerned about any of your results or would like to discuss further with you. However, after you have tests you should check your results on one of the NHS patient apps or, if you are unable to do this, phone our receptionists after 1:30pm to receive the results. Please note that receptionists are not able to discuss the meaning of results, so if you are concerned or would like to discuss them further, please book a routine appointment with a doctor or physicians’ associate.

Please do not contact us to discuss hospital test results as we do not have access to these. Your hospital clinician will contact you about these.

What is a “normal” range for results?

A normal range is chosen by the lab based on statistics and the average population that they see. Normal ranges are set so that 95% of normal results will be within the range. This means that 1 in 20 normal results would naturally be outside this range. This means that if you are completely healthy and have 20 tests, you would be expected to have an average of one result marked as “abnormal” based on these statistical “normal” ranges.

“Normal” ranges are based on an average White British patient. Many ethnicities have different normal values, which are not taken into account by our laboratory. For example, African people often have lower levels of neutrophils (a kind of white blood cell), and South Asian people often have smaller red blood cells. In both cases this is normal for them, and is not harmful, but it would be flagged as “abnormal” by the laboratory.

What is normal for a person also varies by age and factors such as pregnancy, medications taken or long-term conditions. However, the laboratory “normal” ranges do not take this into account.

Some people have particular results that are always slightly outside the statistical “normal”, but it is normal for their body. Just as different people have different faces and hair, laboratory results show a range of variation between people.

My result has an exclamation mark next to it, but the doctor has marked it as normal. Why is this?

As described above, there are lots of reasons why results can fall outside the average “normal” range set by the laboratory. When reviewing results clinicians take into account factors such as your ethnicity, gender, age, regular medications and medical history, as well as your results as a whole and your previous results. This allows them to pick out results that may be significant and need to be discussed with you or followed up with further tests or medication.

Understanding your medical records

What are medical records and why are they made?

Medical records are written notes about your medical care, including what happened when you saw a clinician, your test results, and any medications prescribed.

What do my electronic records include?

Electronic records contain all the medical information that your GP stores about you. This includes consultation notes, test results (for tests that are requested by your GP surgery), prescriptions, vaccinations, and letters from hospital.

They do not include notes made about your care while you are in hospital, or results for tests that are arranged by hospital clinicians.

Why did my doctor write that I was “complaining”?

Many words are used slightly differently in medical notes compared to usual speech. We write “patient is complaining of a headache” when we mean “patient said they have a headache”. We might also write that a patient “reported” something (i.e. they told us about it). Medical language has a lot of idiosyncrasies. For example, you may notice question marks at the beginnings of words and sentences, which is used to indicate “this is possible but we’re not sure”.  

These odd and old-fashioned ways of writing have been passed down between clinicians over hundreds of years, and they go along with the Latin and Ancient Greek words that are used to describe many symptoms and illnesses.

What do the abbreviations in my notes mean?

Clinicians use a lot of abbreviations to describe symptoms, diseases, test results and treatments. Some of these (such as BP for blood pressure, and HTN for hypertension) are widely used and understood. Some can have many meanings, depending on the context (so Googling them may not provide a correct answer). Some will be related to local referral pathways and services. Different clinicians have different abbreviations they favour (for example, I often use NAD = “no abnormality detected”, but other doctors might write “normal” or “N”).

My doctor wrote that I might have a serious illness, why didn’t they tell me?

Whenever a clinician considers a patient’s symptoms, they form a “differential diagnosis”. This is a selection of different illnesses that might be causing the symptoms, and which they want to keep in mind and/or investigate. These will range from common but minor illnesses to rare but serious problems. A large part of our job is figuring out where a problem fits in this spectrum. Any problem could have one of many rare and serious causes, but we do not discuss every possible cause for every symptom, as it would be confusing and unnecessarily worrying. We do discuss likely causes, and if we feel that there is a significant possibility of a serious illness (e.g. cancer) then we will discuss this. We also keep our differential diagnosis list in mind, so that if your symptoms do not respond to treatment as expected, or if you develop new symptoms, then we may consider alternative diagnoses.

Something in my notes is incorrect. Can I get it changed?

If you believe that there are any factual inaccuracies within your medical record, you can submit a written request to the practice to have it amended. We can only consider requests that are regarding factual matters such as an incorrect date or measurement. Please note that other information, such as clinical assessments, opinions, and decisions cannot be changed. We will also not remove information that you would prefer not to be recorded in your medical notes. This includes factual matters such as weight or blood pressure, things you tell us about (such as smoking or drug use), and our clinical assessments or opinions.

If you would like to request an amendment of a factual error, please submit this in writing to [email protected] or by post to Cowley Road Medical Practice, East Oxford Health Centre, Manzil Way, Oxford, OX4 1XD. Include the change you are requesting, the reasons for your request, and your contact details.

Please note that we can not change any records that were not created by the practice, such as hospital letters.

I would like to speak to my GP about my medical records

In order to try and maximise the time GPs spend providing medical care, GPs are not available to discuss medical records. If you would like to discuss your health further, please make a routine appointment with your usual GP. Please be aware that GPs are not able to change your records.