Medical e-charts

[klmama]

Do doctors write down more than what patients can see on their medical e-charts?

[Arcadia]

My doctor visit notes have less than what is in my medical records. Some are internal notes that the doctor makes either for himself/herself or for a colleague if referring. My doctors might also write down notes for my test results but I won't see those notes, only the automatically released test results. For example, I would see the reports from my MRI and mammogram but I may not know if my doctors wrote any notes for their references.

[Jean in Newcastle]

Yes. What I see is definitely less than what is in my records. 

[Tap]

Absolutely! I have seen records sent to other providers that contain much more information. Sometimes it is not important, but once there was a note in my daughters psychiatrist notes that mentioned her being disheveled and sweaty. But he left off that it was a 85* day and I brought her directly in from outside playing because she was having fun, refused to stop playing and get in the car. Which I had explained to him, but he didn't put in the note. It wasn't a big deal, but made me feel like someone could think I didn't keep my child clean. 

[KidsHappen]

IDK, but I do know that you are entitled to a complete copy of your medical records if you request them. You may be charged a copying and shipping charge (usually a small amount). I recently got a copy of my records from rehab. There were a thousand pages and there was not charge but when I got the records from the hospital there were only fifty pages and it was $15. It is my understanding that they can not give you a partial or redacted record so if the doctor left notes in your records you would have access to them.

That leads me to believe that records would basically contain just the facts and certainly nothing derogatory. If your doctor wished to make note of something like that they would probably keep them in their own personal notes not associated with you records. Also with my recent health issues I had to sign forms allowing all of my various doctors at different institutions to access my various records and talk to each other. Although I am not exactly sure what the law is regarding this because it does seem that one doctor was able to pull my records that I don't recall signing an authorization for. I can't be positive though as my memory of the whole events is not so good. Perhaps someone with a little more knowledge in this area could elaborate further.