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Correcting your medical record


klmama
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Our clinic has started posting notes from the doctor visits to our online accounts, and it seems that every time they've recorded something incorrectly.  Left side vs right, stating an allergy vs a suspected allergy, attributing a concern/request for testing to the wrong reason.  It doesn't seem to matter if it was the doctor doing the typing or a scribe.  I could certainly send corrections, but does it matter?  What do you think?

 

 

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6 minutes ago, klmama said:

Our clinic has started posting notes from the doctor visits to our online accounts, and it seems that every time they've recorded something incorrectly.  Left side vs right, stating an allergy vs a suspected allergy, attributing a concern/request for testing to the wrong reason.  It doesn't seem to matter if it was the doctor doing the typing or a scribe.  I could certainly send corrections, but does it matter?  What do you think?

I wish I could see doctor comments. I've caught comments when they've left charts in the room in plain view and found them to misrepresent things big time. I suspect that in systems where a new doctor can see old doctor's notes that this might be why I have trouble gaining traction with the new doctor. 

I am seeing a new doctor tomorrow in the same healthcare system, and I am very worried that I am sunk before he even meets me. The last time I went to my doctor, I was going to get a screening test because both my dad and my child have a major health issue that is often genetic. The doctor made me make up a different reason to get me the test!!! On top of that, her aide had completely misrepresented why we were there in the chart, and when we saw it, we told her to correct it. She changed it but it was still wrong, so we had to untangle a ton of stuff when the doctor came in.

I have literally retyped this three times and lost it, so apparently it's not meant to be, but my doctor makes crap up all the time. That's the long and short. And she offers me unsolicited advice about things I see specialists for, and her advice always contradicts the specialist. She's a piece of work. 

At least with this new doctor, I have paperwork from my optometrist (a patient of his and person that told me about the new doc) that shows mild retinal changes that are consistent with high/irregular BP, so maybe that will help me out. According to my current family doc, my BP issues are due to "white coat-itis." 

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7 minutes ago, kbutton said:

I wish I could see doctor comments. I've caught comments when they've left charts in the room in plain view and found them to misrepresent things big time. I suspect that in systems where a new doctor can see old doctor's notes that this might be why I have trouble gaining traction with the new doctor. 

I am seeing a new doctor tomorrow in the same healthcare system, and I am very worried that I am sunk before he even meets me. The last time I went to my doctor, I was going to get a screening test because both my dad and my child have a major health issue that is often genetic. The doctor made me make up a different reason to get me the test!!! On top of that, her aide had completely misrepresented why we were there in the chart, and when we saw it, we told her to correct it. She changed it but it was still wrong, so we had to untangle a ton of stuff when the doctor came in.

I have literally retyped this three times and lost it, so apparently it's not meant to be, but my doctor makes crap up all the time. That's the long and short. And she offers me unsolicited advice about things I see specialists for, and her advice always contradicts the specialist. She's a piece of work. 

At least with this new doctor, I have paperwork from my optometrist (a patient of his and person that told me about the new doc) that shows mild retinal changes that are consistent with high/irregular BP, so maybe that will help me out. According to my current family doc, my BP issues are due to "white coat-itis." 

Oddly, this makes me feel better, even though it’s terrible. I had this happen regarding something that was super frustrating and unhelpful to have misrepresented by the doctor, and it’s always bothered me ever since. I switched doctors over it because I didn’t trust him after that. It somehow makes me feel better that it wasn’t just something about me. Although that’s bad, because it’s not good for it to happen to anyone.

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I once saw a new doctor in a practice (mine had left) to get a refill on thyroid meds. I was on meds because of radiation tx 20 years earlier. While I have chronic issues from the radiation, I went in to a thyroid refill only. I was exhausted because I had just started college. He noted in the file I was ambivalent about my chronic health condition. *sigh* Apparently being exhausted and only wanting to refill my meds and get on with my life was ambivalence. I quit going to see him after a few more trips where he did similar things. He left the practice a few years later. 

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42 minutes ago, elegantlion said:

I once saw a new doctor in a practice (mine had left) to get a refill on thyroid meds. I was on meds because of radiation tx 20 years earlier. While I have chronic issues from the radiation, I went in to a thyroid refill only. I was exhausted because I had just started college. He noted in the file I was ambivalent about my chronic health condition. *sigh* Apparently being exhausted and only wanting to refill my meds and get on with my life was ambivalence. I quit going to see him after a few more trips where he did similar things. He left the practice a few years later. 

Wow, that's nuts. And also ironic since I have to beg my doc to give even the smallest bit of care about health conditions that are clearly brewing.

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Well, I messaged the doctor with my corrections, and she changed the notes.  I'll be doing that from now on.  You never know when something will matter, either to a future doctor or to insurance being willing/not willing to pay.

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28 minutes ago, klmama said:

Did you switch primary care without transferring records?  Any hassle from the new doc?

Yes. And some, but not overly. It was the third time I'd switched and by then I'd gotten wise to the pattern. Good doctor. Records get transferred. Suddenly doctor acts like I'm a crazy person not worthy of care. So every time they asked me to do the records transfer, I was like, uh-huh, sure, I'll get to that. And then I didn't. They're still treating me like a human being so I consider this a win.

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I tried a new primary care doctor this week, and I am not sure what records he has access to, though things like my Covid shot showed up. The previous family doctor is in the same system, and she is nuts. It went well. He asked if I am always that nervous about medical appointments, and I told him I'd been gaslighted by my last doctor for years and gave some examples. He made sure to tell me before I left that if I have any trouble with anyone in the practice, let him know. He said I would probably only see someone else if I have an urgent appointment, and he is booked, but he wants me to be comfortable and confident in my care.

He was really great. I was so relieved. DH was with me and backed me up, but I am not sure it would've mattered. He really just took my word for things. 

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The doctor's office I took my kids to in a prior town didn't record all of my dd10's vaccinations when she was little.  When I transferred over the kids' records after moving and went to enroll them in the charter school, there was a gap in her records.  I know for a fact I took her in every year at her birthday and had them give her everything she was supposed to have, but they insisted that I must have forgotten those two times.  (Even if I had, they would have still screwed up, because her shot record proceeded after those gaps as though she had had what was due then on schedule).  I couldn't get it corrected, so I elected to complete the requirements for the school as though we hadn't vaccinated, rather than making my daughter get a bunch of unnecessary repeat shots.  I wonder if she will have to have them again at some point, though, just to have the paper trail.

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