Accessing The Medical Chart | Teal
Many treatments have irreversible consequences, so it is worth doing it right the first time. It is commonly understood in medical circles that long-term survival is improved by receiving optimal treatment up front. The first treatment is your best shot at eradicating the cancer.
Be aware, you have every right to obtain and keep your records. Some offices may charge a small fee for providing you with the records. There is no universal format for charts, and some offices keep more complete records than others. It may be necessary to request the information from more than one doctor’s office to compile all the necessary information. You don’t need a complete understanding of everything in the chart. However, there are certain specific items you need to look for:
Prostate Specific Antigen (PSA) Chronology: Construct a chronological history of every PSA measurement that has ever been taken and the date that it was performed. The PSA results can be found in your Lab Reports. The testosterone level is also found in this section of the chart.
Clinical Stage: Information about the digital rectal examination (DRE) will be found in the Progress Notes section of the chart. Results indicate whether a nodule can be felt by the doctor’s finger. The type of nodule that is felt is recorded as the “T” stage. The doctor records his impression of the DRE in the Physical Examination section of the Progress Notes section of the chart per the following table:
T1: No tumor is felt
T2: Tumor feels confined within the prostate
T2a: Tumor that can be felt but involves 50% or less of one lobe
T2b: Tumor felt involving more than 50% of one lobe but not both lobes
T2c: Tumor felt in both lobes
T3: Tumor felt that extends through the prostate capsule
T3a: Extracapsular extension is felt
T3b: Tumor felt that invades seminal vesicle(s)
T4: Tumor felt that invades rectum or bladder
Radiology Reports (imaging studies): The radiology reports will be found in the Radiology section of the chart. Look for the Impression section of the report where the doctor who wrote the report summarizes the essential aspects of the scan results.
Biopsy Report: The biopsy report will be in the Pathology section of the chart. For each of the biopsy cores that contain cancer, you should make note of the Gleason score and the percentage of the core that contains cancer.
Peter Scholz is the Creative Director of the Prostate Cancer Research Institute (PCRI). He received his B.A. in english literature from the University of California, Los Angeles. In addition to branding, design, and media production for the organization, his interests at PCRI are in simplifying, curating, and presenting prostate cancer information in ways that are understandable and accessible to patients.