Most confusion in medicine comes from ordinary words that mean something specific in a clinical setting. "Negative" is good news. "Unremarkable" is a compliment. "Chronic" says nothing about how serious something is.
Here are the ones that come up most, grouped by where you run into them.
Words about your test results
Negative. The thing being tested for was absent. In nearly every case this is the result you want.
Positive. The thing being tested for was found. This describes the test, and it does not tell you how serious the finding is.
Normal range or reference range. The span of values typical for most people. Ranges vary between labs, so the same value can sit inside the range at one lab and just outside it at another. A number slightly outside a range is often unimportant for you specifically.
Unremarkable. Nothing concerning showed up. This is good news, despite sounding like a shrug.
Within normal limits (WNL). Same idea. The result is in the expected range.
No acute findings. Nothing urgent or new. There may still be long-standing findings noted elsewhere.
Benign. Not cancer. Benign growths can still cause problems depending on size and location, and they are not malignant.
Malignant. Cancer, or having the ability to spread.
Inconclusive or indeterminate. The test did not give a clear answer. Usually means repeating it or trying a different one.
False positive. The test flagged something that turned out to be absent. False negative is the reverse.
Incidental finding. Something noticed by accident while looking for something else. Many are harmless.
Baseline. Your starting point, so future results can be compared against it.
Elevated or decreased. Higher or lower than expected. Says nothing on its own about why.
Words in your chart and visit notes
Acute. Recent, or coming on quickly. Chronic means long-lasting. Chronic describes duration only, and plenty of chronic conditions are well controlled for decades.
Presenting complaint or chief complaint. The main reason you came in, in the note's own words.
History of present illness (HPI). The story of the current problem.
Past medical history (PMH). Your previous conditions and diagnoses.
Review of systems (ROS). The checklist of questions about different parts of the body.
Physical exam (PE). What the doctor found when they examined you.
Assessment. What the doctor thinks is going on.
Plan. What happens next. The assessment and plan section is usually the most useful part of a note to read.
Differential diagnosis. The list of possibilities being considered, usually ordered by likelihood.
Rule out (r/o). Something being checked to make sure it is absent. "Rule out pneumonia" means pneumonia is being excluded rather than diagnosed.
Comorbidity. Another condition you have at the same time.
Idiopathic. The cause is unknown.
Asymptomatic. Present without causing symptoms.
Denies. You said no to a question. "Patient denies chest pain" means you were asked and said no. It carries no suggestion of disbelief.
Noncompliant or nonadherent. A note that a plan was not followed. If you see this and the reason was cost, side effects, or unclear instructions, that is worth correcting in the record and worth saying out loud.
Stable. Unchanged. In a hospital, stable means not getting worse rather than doing well.
Prognosis. The likely course ahead.
Etiology. The cause.
Bilateral means both sides. Unilateral means one side.
Anterior is front, posterior is back, proximal is closer to the center of the body, distal is farther away.
Words about tests and procedures
Invasive. Involves entering the body, with a needle, a tube, or an incision. Non-invasive stays outside.
Biopsy. Taking a small tissue sample to examine.
Pathology. The study of that tissue. A pathology report describes what the lab found.
Imaging. Pictures of the inside of the body: X-ray, ultrasound, CT, MRI, PET.
Contrast. A substance given by mouth or by IV that makes certain structures show up more clearly.
NPO. Nothing by mouth. No food or drink before a test or procedure.
Fasting. No food for a set period, usually 8 to 12 hours. Water is often allowed. Ask, because instructions differ.
Elective. Planned in advance rather than an emergency. Elective does not mean optional.
Outpatient. You go home the same day. Inpatient means you stay at least one night.
Observation. A hospital status where you are being watched without being formally admitted. This distinction can affect what your insurance pays, so it is worth asking which one you are in.
Screening versus diagnostic. A screening test looks for a problem before you have symptoms. A diagnostic test investigates a symptom or an abnormal screening result. The same test can be either, and which one it is labeled as can change your cost.
Prep. What you do beforehand, such as fasting or bowel preparation.
Sedation versus general anesthesia. Sedation makes you relaxed or drowsy and often awake. General anesthesia makes you fully unconscious.
Words about medications
Generic versus brand name. Same active ingredient, different name and usually a large price difference.
Dose is how much. Frequency is how often. Both matter, and both belong on any list you carry.
PRN. As needed, rather than on a schedule.
BID, TID, QID. Twice, three times, and four times a day. QD is once daily, QHS is at bedtime.
Titrate. Adjust the dose gradually, up or down.
Taper. Reduce gradually rather than stopping at once.
Contraindicated. Should be avoided in your situation.
Interaction. One medication affecting another. This is why the complete list, including anything you buy off the shelf and any supplements, matters at every visit.
Side effect versus adverse reaction. A side effect is a known and often minor extra effect. An adverse reaction is a harmful response. Ask which ones mean call the office.
Formulary. The list of medications your insurance plan covers. A drug that is off-formulary costs much more, or requires an exception.
Prior authorization. Your insurance requires approval before it will cover something. Your doctor's office submits it. Ask who handles authorizations there and call that person by name if it stalls.
Step therapy. Your plan requires you to try a cheaper option first before covering the one your doctor prescribed.
Refill versus renewal. A refill uses a prescription that already exists. A renewal needs the doctor to write a new one.
Words on your bill and from your insurance
This group causes as much confusion as anything clinical, and it is entirely learnable.
Premium. What you pay monthly to have coverage, whether or not you use it.
Deductible. What you pay out of pocket before your plan starts paying its share.
Copay. A fixed amount for a visit or prescription, such as $30.
Coinsurance. A percentage of the cost, such as 20 percent. Coinsurance usually applies after the deductible.
Out-of-pocket maximum. The most you pay in a year. After that, your plan covers 100 percent of covered services. This number is the one worth knowing.
In network. Providers who have an agreement with your plan, at lower cost to you. Out of network means no agreement, and much higher cost.
Allowed amount or Medicare-approved amount. The price your plan has agreed to for a service. Your share is calculated from this, rather than from the provider's original charge.
Explanation of benefits (EOB). A statement from your insurer showing what was billed, what they paid, and what you may owe. An EOB is a summary, and it is not a bill.
Balance billing. When a provider bills you for the difference between their charge and what your plan paid. There are federal protections limiting this in certain situations, particularly emergency care and some out-of-network care at in-network facilities.
Claim denial. Your insurer declined to pay. Denials are frequently reversed on appeal, often because of a coding error rather than a coverage decision. Ask for the reason in writing, and ask your doctor's office to help.
Appeal. The formal process for challenging a denial. Plans must tell you how, and there are deadlines.
Medical necessity. The standard insurers use to decide whether to cover something. A denial for lack of medical necessity can be appealed with supporting documentation from your doctor.
Superbill or itemized statement. A detailed line-by-line breakdown of charges. Ask for it whenever a bill looks wrong. Errors are common.
Good faith estimate. A written cost estimate you can request before scheduled care, particularly if you are uninsured or paying out of pocket.
Who is who
Knowing the roles tells you who to ask for.
Attending physician. The fully trained doctor in charge of your care. If you want the decision-maker, this is the person.
Resident. A licensed doctor completing specialty training, supervised by an attending. Intern is a first-year resident.
Fellow. A doctor who finished residency and is training further in a subspecialty.
Hospitalist. A doctor who cares for patients only while they are in the hospital. They usually are not your regular doctor and will not follow you afterward, which makes the discharge handoff worth asking about.
Nurse practitioner (NP) and physician assistant or associate (PA). Clinicians who diagnose, treat, and prescribe, working within a practice. Often the person you see most often, and often the person with the most time.
Registered nurse (RN). Provides care, administers medication, and is frequently the fastest route to a practical answer. The nurse line at a practice is underused.
Nurse navigator or care coordinator. Someone whose job is to help you move through a complex course of care. Ask whether one is available. They are enormously useful and rarely advertised.
Case manager. Coordinates services, discharge planning, and sometimes insurance issues.
Social worker. Helps with practical and financial problems, including transportation, home care, and programs you may qualify for. Ask for one when the problem is logistical rather than medical.
Patient advocate or patient representative. A hospital employee whose job is to help resolve problems and complaints. Ask for them when you are stuck.
Financial counselor. Handles costs, estimates, payment plans, and financial assistance applications. Ask for this person before a scheduled procedure.
Pharmacist. Reviews your medications and catches interactions. Free, usually available, and consistently underused.
Radiologist reads imaging. Pathologist examines tissue. Both write reports about you and neither usually meets you.
How to look something up
Ask them to write it down. Correct spelling makes any search far more reliable. Medical words sound like each other.
Ask your pharmacist about anything medication-related.
Prefer sources with a reason to be accurate. Government health sites, academic medical centers, and professional medical societies. Search results and forum threads are a mixed bag.
Ask what they would have you read. Most doctors have a source they trust for your specific condition, and it is a good question to end a visit with.
Common questions
What does unremarkable mean on a medical report?
Nothing concerning was found. It is good news.
Does a negative test result mean I am fine?
It means the thing being tested for was absent. Ask what the test does and does not cover, since a negative result rules out one thing rather than everything.
What is the difference between an attending and a resident?
An attending is a fully trained doctor with final responsibility for your care. A resident is a licensed doctor in specialty training, working under that attending's supervision.
What is the difference between a copay and coinsurance?
A copay is a fixed dollar amount. Coinsurance is a percentage of the cost, and it usually applies after you meet your deductible.
Is an explanation of benefits a bill?
No. An EOB is a summary from your insurer of what was billed and paid. Any amount you owe arrives separately from the provider.
What does chronic mean?
Long-lasting. It describes how long a condition persists and says nothing about how severe it is.
Why does my chart say I "denied" something?
It records that you were asked a question and answered no. It carries no implication of doubt about your answer.
