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A Piece of My Mind
February 2, 2016

My Body, Your CrimeThe Anatomy of a Medical Note

Author Affiliations
  • 1University of California, Davis School of Medicine, Sacramento

Copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA. 2016;315(5):463-464. doi:10.1001/jama.2015.16760

Dear N,

I thought about you the other day. I was in class, learning how to write a proper medical note for a patient encounter. My thoughts wandered, and I began composing sections of a medical note that I assume make up the contents of my own medical record from the emergency department visit I had made years ago after we first met.

Like all records, my note will open with key identifiers: the medical record number, date of visit, my name, date of birth, age, and sex. The chief concern, or main reason for my visit, will begin the official “subjective” portion of my medical record. It probably reads in one sharp and straightforward sentence: “Vaginal bleeding and pain status post sexual assault.”

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