Medical terminology refers to the result of a medical examination on a patient as a finding. This includes mental exploration, physical examination, and laboratory and instrumental medical tests.
What are the findings?
Medical terminology refers to the result of a medical examination on a patient as a finding. The medical term finding refers to holistic examination results as well as to partial findings. A constellation of findings exists when several findings are determined. On the basis of this constellation of findings, the attending physician makes the diagnosis, taking the patient’s medical history into account. The anamnesis includes questioning the patient about his or her health history, living conditions, any allergies, current complaints and determination of the genetic risk constellation. The findings are recorded in a medical report. The findings report summarizes qualitative and quantitative statements. A qualitative statement is, for example, when the patient’s findings are negative for bronchial disease “bronchi clear”. A quantitative statement is, for example, when the cholesterol level is found to be “total cholesterol 200 mg/dl”.
Function, effect, and goals
In the case of certain complaints and diseases, detailed examinations are indicated. These examinations are performed by specialists, because general practitioners often do not have the opportunity to perform them in the office. These examinations are carried out, for example, as further examinations in the case of an initial suspicion of a tumor disease. Histological and laboratory examinations are necessary, which are performed by specialists, radiologists and pathologists. These examinations can be, for example, microscopic examinations of specimen collections. Laboratory findings include the test results of urine, blood and other body fluids. In almost all medical fields, it is not possible to assess the health situation of patients without laboratory findings. The results of these laboratory examinations enable physicians to make a final assessment of the patient’s health status and to determine effective treatment options. In order to clarify the abnormalities and the patient’s complaints, the general practitioner refers the patient to a specialist by means of a referral slip. The result of the medical examination is the diagnosis. In many cases, this comes one to two weeks later. It is sent to the family doctor. The general practitioner then discusses the findings with the patient, explains the results and discusses the specialist’s suggestions for further action. Histological findings provide information on the microscopic analysis of a tissue sample, while pathological findings describe the pathological changes in a tissue sample. Causal findings not related to the main disease are called incidental findings. Incidental findings appear during the main examination without the attending physician having specifically looked for them beforehand. A finding is positive if the examination confirms the initial suspicion. If a patient is examined for cancer and it turns out during the examination that a malignant tumor is present, the cancer finding is positive. The finding is negative if the examination does not confirm the initial suspicion and the patient is tumor-free. Medical terminology uses these two terms in a different way than everyday language. With the word “positive” people associate something pleasant, but the positive finding warns that the patient’s health condition is developing unfavorably and something abnormal has been found. With the word “negative” people associate unpleasant situations, but in the case of a negative finding they have reason to be happy, because it says that the initial suspicion is not confirmed and the suspected disease is not present. If the physician detects an AIDS disease in a patient, he is “HIV-positive”; if the disease is not present, he is “HIV-negative”. The distinction from the term “symptom” is that the finding describes the empirical character of documented characteristics, i.e. the collection of information, whereas the symptom emphasizes the appearance of the characteristic as an indication of a disease.However, a report of findings can prove to be a closed book for affected patients, as most people do not understand medical terminology. They perceive it as difficult to understand, both subjectively and in terms of technical language. Since this technical language is part of everyday professional life for physicians, they often do not take into account that their patients do not understand it in most cases. Even if physicians are able to explain the respective findings to their patients in a way that is easy to understand, in their excitement they may forget what was said and subsequently stand alone with their findings and the incomprehensible technical language. There is a great need for easy-to-understand explanations in the report of findings. Lay people need a “translation” of the doctor’s Latin, because easy-to-understand language puts many patients at ease and makes even complex and troubling findings easier to bear.
Risks, side effects, and dangers
This disparity has now also been discovered by the scientific community, which is working to remedy the situation. The University of Dresden celebrated a Germany-wide premiere in the 2014/2015 winter semester with the elective “What have I got?” The project at the TU Dresden was funded by the Stiftung Hochschulmedizin, and the concept was conceived by medical students. The elective aims to improve communication between doctors and patients in a practical way. Initial course evaluations show significantly improved communication skills with a high level of practical relevance. An expansion of this offering to other universities in Germany is planned. The preparation and documentation of a report is one of the most important duties of a physician with regard to the proof of performance in billing matters and in the event of legal disputes. Main complaints, concomitant complaints and initial suspicions lead to a tentative diagnosis, which results in the specific diagnostic findings and the working diagnosis. Subsequent treatment and therapy of the disease are based on the findings survey. Structured documentation of findings supported the cooperation and communication between the involved physicians, patients, institutions and clinics. The development of telemedicine supports this structured approach in the long term. Standardized findings are easier to compare and disease progression can be better assessed. The risk of misunderstandings between the medical professionals involved is largely eliminated. The Patients’ Rights Act obliges medical practitioners to keep a patient file containing all relevant findings and information in accordance with Section 630 of the German Civil Code.
