Why would a doctor put this in a visit summary?

[I talk to the trees]

Thanks, all! I think she has decided how to proceed. 

Edited Sunday at 05:47 PM by I talk to the trees
Decision made

[mommyoffive]

Well I have no medical background so I am interested in what anyone with that would say about that.  

But putting that they are wearing a mask in there is just hitting me wrong right now.  It is hard for me to not think of it different light.

Edited September 28 by mommyoffive

[KSera]

Given that it followed directly from the n95 note, I would be concerned this was a between the lines suggestion that both these things were unfounded, anxiety related things.  I base that on having heard similar stories from people with more explicit wording to that effect. No, I don’t personally think that belongs in the medical record as it’s based on a completely biased interpretation on the part of the physician. Even worse when the patient in question is the one following health guidance!

[klmama]

Whether or not things like that should be in the record, they often are. In my experience,  it happens more often when the doctor has a scribe typing notes. 

[Ann.without.an.e]

With those together, they were no doubt attempting to draw attention to her political leaning. The question is, why? Do they want to have it on record that certain issues are impacting people and their decisions or is it to make her look paranoid and anxious? One could never know really. 

[Red Dove]

The few times I have looked at the doctor’s notes, pretty much everything we talked about is in there. I previously had no idea they put every comment into the notes. 
I can’t help but feel a bit defensive about it. It does not make me want to communicate freely. 

[Serenade]

26 minutes ago, Red Dove said:

The few times I have looked at the doctor’s notes, pretty much everything we talked about is in there. I previously had no idea they put every comment into the notes. 
 

I have noticed this as well, and I have asked for things to be removed without any issues.

[Red Dove]

13 minutes ago, Serenade said:

I have noticed this as well, and I have asked for things to be removed without any issues.

I didn’t know you could ask for things to be removed. Will they then put it in their notes that you asked for something to be removed? 😂 

[Kassia]

2 hours ago, Red Dove said:

I didn’t know you could ask for things to be removed. Will they then put it in their notes that you asked for something to be removed? 😂 

I had incorrect information put in my office visit notes and I requested for it to be removed and they refused to do it.  It makes me really angry.  

@I talk to the trees I would definitely ask to have that removed if I didn't want it in there especially since it has nothing to do with any health issues that could be useful in the future.

[Katy]

I would assume either the practice or their insurance required documenting everything OR the doctor felt it was a sign of general anxiety.

[MEmama]

Oh hells to the no. Totally inappropriate and unnecessary. I hope this person is able to get the comments removed from their notes. There's only one reason to put that information in there, and it's not to benefit the patient.

Further, I hope they can find a new doctor ASAP. 

[MercyA]

Why in the world is the doctor concerned that she's wearing a mask?  And making a record of a political conversation? Unprofessional, creepy, unacceptable. 

I'd contact the office and say something like, "I recently noticed notes about my personal views in my medical records. They are in no way relevant to my treatment or visit. Please remove the following portion from my record from X date: [...]." 

[City Mouse]

Without seeing the rest of what he wrote, I think people are assuming way too much about the doctor’s intentions. 
The doctor might be totally biased, but the doctor might also agree with the patient. It is impossible to tell from just those few sentences. 

[Carrie12345]

If the doctor suspected anxiety, the doctor has a responsibility to bring up anxiety for dx and treatment. If they did not, they’re a crappy doctor.  
For that reason, I don’t buy that explanation.

[Katy]

43 minutes ago, Carrie12345 said:

If the doctor suspected anxiety, the doctor has a responsibility to bring up anxiety for dx and treatment. If they did not, they’re a crappy doctor.  
For that reason, I don’t buy that explanation.

No they don’t. They have a duty to provide whatever care the patient requested as the purpose for the visit. They don’t have to address anxiety unless directly asked, and as it is even if they suspect anxiety, there is little evidence anxiety is affecting their daily life. Declining to move to a state where women might die from lack of healthcare may be anxiety, but it isn’t crippling anxiety. 

[Annie G]

Is it possible he’s using the notes to keep track of what’s going on in her life?  For years we had the same doctors but I still always wondered how they remembered the stuff they talked about when they first came into the room. Then I realized my primary doc talked about two things he knew about me and only those two- a football team I followed and the car we bought for pleasure rides.  I assumed he had it in some notes somewhere.  
I’m not defending him putting those comments in her notes, just trying to find an explanation. 
 

[Faith-manor]

Sadly, having had doctors ask me HIGHLY inappropriate questions before - literally not a damn thing related to health and medicine at all and VERY intrusive and unprofessional like "so how good is your husband in bed" - I no longer allow any chit chat in any appointment. None. I am literally the vault, and I give resting bitch face if an inappropriate question is asked. Since I know for a fact that what should have been incredibly protected conversation and information was released by my then GP to our car insurance company after our car accident, I have NO trust now. I assume all doctor office will sell their patients down the river to insurance companies. Nothing like having your car insurance agent say to your face, "We knew about your PTSD from your medical records, so it wasn't a surprise when you sought out a therapist, but the company is going to fight not to pay the bills." Our lawyer didn't get anywhere fighting the HIPPA violations.

Sad to say, you have to be on your toes, and be very guarded.

OP, your dd should demand this be removed from her record, and if it isn't, get a lawyer to make the demand which will probably move the needle. She should get a new doctor, and then sadly, clam up at appointments giving out only pertinent medical information. If she masks, which is a good idea, unfortunately, she probably cannot stop that from being entered into her record because it is, after all, a legitimate health precaution that she is choosing to take so they can legitimately claim it is medical information that should be recorded. I think it is wrong. But I think this particular thing cannot be stopped either. Questions about future plans moving, reproductive politics, etc. are questions she should not answer, and I would turn it back on the practitioner, "Is this really relevant to why I am here today?" Or simply ignore the question, fake a sneeze in the moment whatever.

Edited September 28 by Faith-manor

[EKS]

Maybe the comments were just there to indicate that the patient appears to care about her health.  (Isn't it normal to wear a mask at a doctor's office?  I mean because sick people?  All of the employees at my own doctor's office, which is a large clinic, wear them.)

[KSera]

Thinking about it more, my interpretation would be influenced in part by whether the physician was wearing a mask while providing care. I wouldn’t take the note the same way from a Dr who was also masking up as from one who was not. I don’t know if there’s a good explanation for the other comment. I haven’t read any notes of that kind of nature in my record before. Though I did have an occasion where a doctor had put completely false information about me having expressed some thing that I absolutely, 100% did not. I did write to the office about that, but never heard back and I’m sure my record wasn’t changed. I never returned to that doctor.
 

I will say, I had a recent doctors visit and when I read the notes in my after visit summary afterward, the doctor had a section at the bottom labeled, “a note to my patients reading these notes“ explaining that the notes are not written with the patient as the intended audience, but for himself, to help him remember the visit later. 

[Nichola]

Doctors see a lot of patients, and they sometimes put things in their notes to remind themselves of what patients said. In this instance, I would assume that the doctor saw these things as areas of concern to the patient, and he put them in the notes to remind himself to address those concerns with sensitivity in the future. If what was quoted was accurate, he did not put forth his own opinions, merely stated what happened. The patient agrees that these things actually happened. To assume a political agenda behind these basic statements of fact is unfair to the doctor. I would not expect the doctor to remove the notes. For one thing, it is illegal. You can cross something out of notes, and explain why you crossed it out, but you can’t actually delete notes. For another, the courts would uphold his right to document facts about the patient in her chart. There have been cases where doctors have gotten into trouble for writing things about patients’ physical attributes in patient notes. That is very different from what is happening here. Under the given circumstances, I would assume good intentions from the doctor and not jump to conclusions about political bias when he was only stating facts (that the patient agrees happened) about the appointment.

Edited September 28 by Nichola

[SKL]

2 hours ago, City Mouse said:

Without seeing the rest of what he wrote, I think people are assuming way too much about the doctor’s intentions. 
The doctor might be totally biased, but the doctor might also agree with the patient. It is impossible to tell from just those few sentences. 

I was wondering what some doctors would say about the OP, because I really don't know.  A couple thoughts:

1) There are now recording devices that supposedly know how to take notes (our financial advisor was using one the other day).  Supposedly they do a good job of picking out the important points and summarizing them.  I have no idea how this technology works but I could see how a non-human technology could choose points a human might have filtered out.

2) They might be tracking data for one or more studies.  For example, I could see how doctor practices might have agreed to track what % of their patients choose to wear a mask in the appointment, for non-nefarious reasons.  It's even possible that they might have a non-nefarious reason to document that some patients consider certain state laws to be relevant health issues.

3) I wouldn't know if the doc agreed or disagreed based on the notes.  Not that that necessarily matters.

4) I don't assume doc practices waste time sharing these notes with each other for nefarious reasons, given how little time they tend to spend with each patient.

5) I wonder how important all of these notes are.  When my kid was 6, I was advised to take her to see a developmental pediatrician as a step to figuring out some learning difficulties.  I read the notes afterwards.  The first part was about what we discussed in the appointment, but then it strangely shifted to information about what was clearly an infant (head circumference, ability to pull self up but not walk etc.).  The same practice also always added a bunch of irrelevant boilerplate notes, such as that my kid (with BMI <3rd %ile) needed to exercise more and eat more fruits/veggies, and that I should consider whether my then-1st graders were ready for KG or not.  So as far as I'm concerned, those notes are meaningless except (maybe) as a record of what your numbers were, which shots you got that day, and maybe referrals for additional services.

Edited September 28 by SKL

[kbutton]

53 minutes ago, Nichola said:

To assume a political agenda behind these basic statements of fact is unfair to the doctor.

Around here it would not be. We have docs around here stating that Covid is man made, and therefore, it’s pointless to mask. The same doctor’s staff actively tries to get people to stop masking if they see you wearing one.

Maybe it’s unfair to this specific doctor, but if this doctor was wearing a mask himself, I don’t think someone would be questioning the note.

Being accused of anxiety for wearing a mask is par for the course around here.

[kbutton]

24 minutes ago, SKL said:

2) They might be tracking data for one or more studies.  For example, I could see how doctor practices might have agreed to track what % of their patients choose to wear a mask in the appointment, for non-nefarious reasons.  It's even possible that they might have a non-nefarious reason to document that some patients consider certain state laws to be relevant health issues.

I think if they do this, they would need to ask for consent for the study, but I don’t know for sure.

1 hour ago, EKS said:

Maybe the comments were just there to indicate that the patient appears to care about her health.  (Isn't it normal to wear a mask at a doctor's office?  I mean because sick people?  All of the employees at my own doctor's office, which is a large clinic, wear them.)

Without the comment about not wanting to move, I would agree. And no, in huge parts of the country, it’s not normal to ever mask in a doctor’s office.

Around here, the major children’s hospital has a few maskers and probably a policy for HCWs to mask/offer to mask if the patient is masked. Very few patients mask. A few patients are masked while the parents are not, which seems self-defeating. You don’t see masking in regular hospitals much unless the provider is just kind and mirrors your mask.

Otherwise, you have to go to Trader Joe’s to reliably expect to see a mask. That’s not sarcasm.

[KSera]

7 minutes ago, kbutton said:

Around here, the major children’s hospital has a few maskers and probably a policy for HCWs to mask/offer to mask if the patient is masked.

I know someone who just had to take their health compromised child for an inpatient stay at a Children’s Hospital and it was appalling how much pushback they got from HCWs not wanting to mask up in her child’s room because “we don’t have to anymore.” This in an area currently experiencing very high rates of Covid transmission with somewhere around 25% of hospitalized Covid patients having acquired that Covid infection while in the hospital for something else. 
 

I’m disgusted and appalled by how little even many healthcare workers care about protecting other people anymore.

[Nichola]

Concerning the mask, we should keep in mind that the mask would have prevented the doctor from seeing all of the patient’s face during the appointment. Usually doctors include a physical description of their patients, noting anything they may be concerned about. Documenting that the patient wore a mask may just be the doctor’s way of saying, “I couldn’t see her whole face. Therefore, it’s possible I could have missed something relevant to the patient’s condition.” Doctors are supposed to take the whole body into consideration, and the face gives important clues to the health of the whole body. If there was a court case, it would be important for the doctor to have a reason for why he didn’t examine the patient’s whole face. The note in the patient’s chart could just be a case of “CYA.” Documenting that the patient wore a mask seems reasonable to me for several reasons, none of which include politics or anxiety.

[Ann.without.an.e]

Not to get off topic but no one here has masked for a while. Not even in doctor’s offices. They ask you to mask if you have Covid symptoms but rarely does anyone do it. 
 

I thought this was the standard everywhere now. Is it not?

[SKL]

11 minutes ago, Nichola said:

Concerning the mask, we should keep in mind that the mask would have prevented the doctor from seeing all of the patient’s face during the appointment. Usually doctors include a physical description of their patients, noting anything they may be concerned about. Documenting that the patient wore a mask may just be the doctor’s way of saying, “I couldn’t see her whole face. Therefore, it’s possible I could have missed something relevant to the patient’s condition.” Doctors are supposed to take the whole body into consideration, and the face gives important clues to the health of the whole body. If there was a court case, it would be important for the doctor to have a reason for why he didn’t examine the patient’s whole face. The note in the patient’s chart could just be a case of “CYA.” Documenting that the patient wore a mask seems reasonable to me for several reasons, none of which include politics or anxiety.

Good point, and it also could be because they might be documenting or tracking any possible effect that wearing a mask may have on any of the numbers/concerns being recorded.

[KSera]

12 minutes ago, Nichola said:

Documenting that the patient wore a mask may just be the doctor’s way of saying, “I couldn’t see her whole face. Therefore, it’s possible I could have missed something relevant to the patient’s condition.”

This is a good point I hadn’t considered. 
 

 

10 minutes ago, Ann.without.an.e said:

Not to get off topic but no one here has masked for a while. Not even in doctor’s offices. They ask you to mask if you have Covid symptoms but rarely does anyone do it. 
 

I thought this was the standard everywhere now. Is it not?

I think it’s more common than not but far from standard everywhere. We have some hospitals that intermittently are requiring masks for all healthcare workers, depending on how much illness is circulating, and then there are plenty of individual clinics outside the hospital that have this as a standard policy they have never dropped. Which, now that we understand so much more about how airborne diseases are spread and that more diseases are airborne than we realized, only makes sense. No one should leave the doctor’s office sicker than they were when they arrived.

[PronghornD]

This has been an enlightening thread for me. I never even knew that there were notes that I could view! So, I just read up on my last physical and found out all about myself lol. I have been out of touch!!

[Wheres Toto]

3 hours ago, Annie G said:

Is it possible he’s using the notes to keep track of what’s going on in her life?  For years we had the same doctors but I still always wondered how they remembered the stuff they talked about when they first came into the room. Then I realized my primary doc talked about two things he knew about me and only those two- a football team I followed and the car we bought for pleasure rides.  I assumed he had it in some notes somewhere.  
I’m not defending him putting those comments in her notes, just trying to find an explanation. 
 

I could see this and figure he put it in so he knows not to mention the possibility of moving south again. 

I had a pediatrician (just recently retired) that I knew for 30 years but we generally only went once a year.   I'm sure there were all kinds of notes in our files because she would bring up things all the time that I seriously doubt she just remembered given the number of patients she had. 

[Anne]

5 hours ago, City Mouse said:

Without seeing the rest of what he wrote, I think people are assuming way too much about the doctor’s intentions. 
The doctor might be totally biased, but the doctor might also agree with the patient. It is impossible to tell from just those few sentences. 

But whether or not he agreed with the views, this kind of thing doesn’t belong in a medical record, imho.  

[Janeway]

I had a friend who was a doctor who would write personal things like that in to her notes just so that she could remember things about the patient to help with interacting and making the patient feel remembered. It is possible that that was the doctor's intent but it accidentally ended up in the summary that went to the patient.

[I talk to the trees]

Thanks for the replies, everyone. I am trying very hard to give this doctor the benefit the doubt, as this doctor is very accommodating when it comes to requests for referrals, which are needed right now, but felt very uncomfortable with *both* of those comments being included together. The first one I could see as being data-driven:  How many patients are doing X? But the second one was concerning, especially combined with the scripture-laden calendars and framed artwork in the building. (Then again, we’re in the south, so maybe that’s because many patients find that comforting?)

I encouraged the patient to ignore the first issue and send a quick note through the patient portal to ask why the second bit was recorded. 

 

[Janeway]

18 hours ago, I talk to the trees said:

Thanks for the replies, everyone. I am trying very hard to give this doctor the benefit the doubt, as this doctor is very accommodating when it comes to requests for referrals, which are needed right now, but felt very uncomfortable with *both* of those comments being included together.

 

One time, I read in my records where the doctor commented on my make up, right down to where my lipstick was a little crooked. I was in college at the time. It really bothered me then and still bothers me. Now, when I see a doctor, I am always thinking about everything from my outfit to if I shaved, to everything. It is so rude of a doctor to include stuff like that. I know sometimes it could be because they are keeping their own notes so they can be personal. But, I also think some times, they are just arrogant and thinking they have the right to stand in judgement like that. They need to stick to their jobs. The commentary is unprofessional.

Edited Monday at 11:54 AM by Janeway

[kbutton]

11 hours ago, Janeway said:

One time, I read in my records where the doctor commented on my make up, right down to where my lipstick was a little crooked. I was in college at the time. It really bothered me then and still bothers me. Now, when I see a doctor, I am always thinking about everything from my outfit to if I shaved, to everything. It is so rude of a doctor to include stuff like that. I know sometimes it could be because they are keeping their own notes so they can be personal. But, I also think some times, they are just arrogant and thinking they have the right to stand in judgement like that. They need to stick to their jobs. The commentary is unprofessional.

That’s nuts!

[kbutton]

I had to paraphrase from memory to my provider husband, and his take is that it ranged from not helpful at all to the patient/not patient centered to this being a way to label her as a special snowflake. He can’t think of a good reason for it to be in there.