Wrong diagnosis and medical records

[Dobela]

So, what do you do with this? My dd has begun visits with a neurology clinic at the nearest children's hospital to rule out CP. At the end of the first visit with the Nurse Practitioner and a couple of PTs orthotics were prescribed (SMOs). When my dd's regular PT started asking questions I called the clinic and asked for notes or reports that would help the therapists here better understand the reasoning behind the SMOs. The notes I received say that the SMOs were needed because my dd has left hemiplegia. Left Hemiplegia?? That means she has paralysis on the left side of the body! She isn't paralyzed on the left side of the body. In the visit I was even asked if she was left dominate because she was only using her left hand at times. (She is right handed but has begun using her left some in the last few months). I was told that the SMOs were to help with pronation and to give ankle support since she is so flat footed and obviously having balance issues.

 

I have a return visit scheduled in August with the same person. DDs regular PT is concerned that the diagnosis was made just to make sure insurance paid for the SMOs but then the concern is this wrong diagnosis following dd in the future. So, how do I approach this? Anyone else had this happen?

[Orthodox6]

Make sure that the wrong charts were not pulled. Even with computer-based systems, patient information sometimes is filed in the wrong place.

 

As you appear to agree with the balance troubles for your DD, is it possible that you are dealing with "wrong diagnosis" but "right therapy" ? Just pondering the possibilities . . .

[Dobela]

Make sure that the wrong charts were not pulled. Even with computer-based systems, patient information sometimes is filed in the wrong place.

 

As you appear to agree with the balance troubles for your DD, is it possible that you are dealing with "wrong diagnosis" but "right therapy" ? Just pondering the possibilities . . .

I think the therapy is right. Our local PT has said all along that dd was boarderline for orthotics but she was chosing not to use them because some boarderline kids can make good progresss without them and eventually not need them. My concern is more along the lines of will this diagnosis negatively effect her in the future? Or effect her insurance oir insurability in the future?

 

The records I received were pulled from the computer and just printed out. They are the notes entered from the visit by the person making the SMOs and the people who saw her in clinic. I was having her SMOs fitted when the neuro dept returned my call. Since I was already downstairs at the hospital the person on the phone said she would print out what she saw and bring them down.

 

ETA: My dd's name was on the print out and her name was used in the notes so I am assumming those are correct. I am not ruling out the possibility that at some point someone began wrirting about another child in her records or forgot what was actually seen in the visit.

[ondreeuh]

I think that is definitely worth following up on. When I get medical records, I often find small errors. Paralysis is not a small error! Let them know you need to have the records corrected so that they will be useful, and ask that an updated copy be sent to you.

[Plink]

My sister had a wrong diagnosis that followed her for YEARS. She finally was able to move, switch doctors, and she refused to allow them to access her medical records. She got a fresh start and finally got treatment that made sense.

 

Her chart also stated that she was refusing medication for this incorrect diagnosis, so several doctors refused to give her medication that she truly needed saying "well you won't take it anyway."

 

Even if the wrong diagnosis is well intentioned, it is wrong. If something were to happen and your DD was brought to a hospital without you, they would only have the info that is in her chart to work with. Make sure that the info is correct.

[NittanyJen]

This can really be a problem.

 

*Doctors are not supposed to, but sometimes they (or the transcriptionists) will copy and paste from another patient's chart, and forget to edit the name and details, even in EMR (electronic medical records).

 

*I was once prescribed a medication for a short-term, off-label, but very common, usage. The insurance company cannot get it through it's head, and still thinks I have the chronic condition for which that medication is prescribed and is very concerned that I don't seem to be obtaining my refills, and sending me Medicaid forms and trying to put me in contact with a social worker to see why I'm not taking my "very needed" medication (not needed at all, thanks). Errors in the medical record can dog you for YEARS.

 

*Heaven help you if your daughter is in any type of car or work accident. "It says right here in her medical record; she was already paralyzed on her left side." Those people get to see more of your medical records than YOU typically do. Trust me, I've been there.

 

It's not a minor issue. And if your insurance company finds out and thinks you knew about it, they could sue you for fraud.

[Dobela]

THank you for sharing with me. I am going to address this with the hospital that has this on her records. Our local pediatrician will be checking into it as well. She says that it can be a 'working diagnosis' that is considered temporary but until we see the rest of the records we won't know. She also says that hemiplegia can have degrees of severity from very mild to very severe. I don't know how you can be 'a little paralyzed' but I am going to trust her for the moment. Since we are working to rule out a very mild possiblity of CP, I guess that is why that weas put there - but I still don't agree.

 

Thanks again for your input. I am glad to know I wasn't over reacting.