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Medical records vent

denali_iceddenali_ice Posts: 28
edited 06/11/2012 - 8:52 AM in Water Cooler
I am submitting my pain clinic chart notes to AFLAC so I had to pick them up the other day (FINALLY) as I've been dragging my feet on this for several weeks. Anyone else get on edge when reading their medical records and coming across inconsistencies?

-patient rides her bike 2-3 hours a day without pain (no! USED to do do so...you know before the whole pain issue)
- commented about testing different muscle groups including biceps. (Nope...biceps? that was NEVER done at any visit.)
- commented that I am on topamax for migraines. (Nope, he put me on it for nerve pain... it has reduced my migraines!)
- commented that I requested the referral to the surgeon (I finally agreed to it after two months of him suggesting it to me)

Just a few examples, of course.

The physical therapy chart notes are much more accurate, as I've noticed is often the case in my experience.

The mind wobbles, you know.


  • dilaurodilauro ConnecticutPosts: 9,832
    reason your medical records are Yours! You are entitled to see any of the medical records produced by any medical professional.
    Normally, there is a fee per page.

    But, if you ever have doubts or moving from state to state, I would pay the money and review your charts.

    EMR (The future of Medical Records) is going to be here faster than most of us can realize. I think it is prudent for everyone to make sure their records are in order
    Ron DiLauro Spine-Health System Administrator
    I am not a medical professional. I comment on personal experiences
    You can email me at: rdilauro@veritashealth.com
  • Ron,

    What I've been doing in the last year and a half (after having to pay big bucks for my records in bulk!!!) is after my appointment is done, I ask for a copy of that days exam report from the desk staff. So far, doing it this way, no charge. :)

    Also too, I've looked and saw these exams I didn't have! I wonder if they use default software or something: If this box isn't checked, it must have been done and is fine?

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • denali_ice said:
    Anyone else get on edge when reading their medical records and coming across inconsistencies?
    Oh yeah! I read in my records that I took my "daughter" into the appt with me & had to give her a time out for about 5 minutes for acting up. First of all, I have no daughters, only two sons and they are grown men who I think would be very disturbed if I took them in with me at my appt., let alone gave them a 'time out' for bad behavoiur.. :?? This sounds funny, but there were other, more serious discrepencies that made me feel rather insulted. Even still, there was one major issue that was completely left out.

    If your records are not in order you can discuss this with the Dr. and have things changed, but I would not count on it, and if it is a lot of different things or happening on a regular basis, they might think it is you with the *memory* problem, instead of taking responsibility upon themselves. Brenda has the right idea with getting the records fresh after each visit. In my case I changed Drs after reviewing my records because they were pretty shabby, but I talked to my PCP about it, she read the records and was able to see a lot of this herself. Not everything of course, though I kept her up with everything, they can't just go by hearsay and she suggested I change PMs. She was the one who referred me to that PM.
    Anyway, to answer your question...yes...lol.

  • As important as it can be in some situations in the future, such as finding a new insurance provider - I almost feel that patients should have to sign off on their own charts alongside the Dr after everything is transcribed.

    I knew that there would be incorrect info in there. The man would ask me at every appt if the pain pills make me nauseous. No, the pain level makes me nauseous - this is why YOU prescribed Zofran.
  • My GP doesn't push or endorse patients to get a copy of the exam notes, but at the same time, she is very open to a patient pointing out things that aren't right. As she put it to me, "Sometimes I have 3 or 4 patients at the same time, and things *do* get mixed up."

    In my brain though not thrilled she mixed us up, at least she was straight and honest with me on the umm 'boo-boo's' :)

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
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