Sweetz
Diamond Mind
Reged: 05/11/02
Posts: 773
Loc: Texas!
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I am in the process of changing neurologists because the one I have is not respecting me or answering my questions, etc. I asked for my records of EEGs, etc. I read his report for each visit. On some of the records, he lied! He said after my seizure, the hospital gave me Dilantin which is untrue. His notes state that he told me to stop taking it. I never started! My 13 year old daughter could write better notes. They are not professional in the least! They also show that he did not listen to me because he wrote things all wrong. I never said my headaches went away for months, I have always had them every month since I started having them. After reading it all, I highlighted the wrong things. I told my PCP I would give her a copy and let her know what was wrong. He's even got the wrong dosage and drugs on there. I just can't believe this man went to medical school and treated me. He can't even write a sentence properly.
Now, I suspect that Docs do dictation and someone else writes up the report. But, the things he put in his dictation were just plain BS. A lot of it was just him babbling. Frankly, I'm appalled.
Has anyone else seen their records and experienced this?
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"If you choose not to decide you still have made a choice."
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neonsign2003
Moderator at norcoworldwide.com
Reged: 12/26/02
Posts: 566
Loc: midwest
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yes, i had the same problem. I called, said the records were not accurate, not complete and that any "personal notes" on my file must contain a addenum, producing where, when how, this was added to my records. just tell them they are not complete, accurate,etc. tell them you know about you rights to complete disclouse of records and if they can't comply with the laws , you will hire a laywer. worked great for me! I AM STILL GETTING "UPDATED" RECORDS! AFTER PHONE CALL TO MEDICAL RECORDS DEPARTMENT, I WAS GETTING A RESPONSE WITHIN 24 HOURS. NEVER LET THEM THINK THAT YOU ARE NOT AWARE THAT YES, EVEN DOCTORS, MUST JUMP THRU THE HOOPS YOU SET UP.............GET MEAN AND STAY MEAN! 
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I am a moderator at the norcoworldwide.com forum.
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wat853son
Member
Reged: 04/28/03
Posts: 150
Loc: USA
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Mention terms like HIPAA (new privacy rule, see link), Risk Management and JCAHO - they should quickly make the record accurate. HIPAA does "provide patients the right to examine and obtain a copy of their own health records and request corrections."
http://www.hhs.gov/ocr/hipaa/
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Sweetz
Diamond Mind
Reged: 05/11/02
Posts: 773
Loc: Texas!
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thanks ya'll. Well, since I'm never going to see him again, I don't think I'll do anything about it. it just pisses me off. He noted the wrong script, but the staff made a copy of the script itself, which is right, so it can be verified. No wonder he could see me in 2 days..........
thanks again.
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"If you choose not to decide you still have made a choice."
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LumbarSpasm
Silent Chaos
Reged: 05/07/02
Posts: 1538
Loc: USA
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Sweetz, it sounds like someone else's problems got notated in your chart. The Dilantin and lack of headaches for months at a time, make it seem like the doctor was talking about a different patient.
I'd bring that up to the doc!
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LumbarSpasm
Or just a pain in the butt?!
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Beetlenut
Threadhead
Reged: 09/09/02
Posts: 765
Loc: Colorado
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Yea Sweetz:
Bet this one is a new one for ya':
If you ever see the acronym "WNWF" on your medical records it means "Well Nourished White Female"; in other words "FAT"!!!!!!! 
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Sweetz
Diamond Mind
Reged: 05/11/02
Posts: 773
Loc: Texas!
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well, lovely, I'm a "well-developed, well-nourished white female". I'm not fat though. I'm maybe a few pounds overweight. What does the "well-developed" part mean? I do have a big chest.  Could that be the developed part? Who knows. I'll never see him again, so I don't really care to correct anything, it just pisses me off.
My sister (an RN) says it sounds like he got me mixed up with someone else, but what are records for, if they aren't correct?
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"If you choose not to decide you still have made a choice."
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IMSUSCOT1
Threadhead
Reged: 10/23/02
Posts: 925
Loc: usa
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I worked in a Peds ICU for years and these docs see maybe 15 patient's /daily, several times a day, and documentation is always left to the end of the day....Docs who haven't been bright enough to embrace technology, *i.e. a simple small tape recorder, to dictate their encounter with a patient immediately after seeing the patient are all guilty of this...there's just no way to keep the details for that number of patient's straight in your head until the end of the day! And it can have disasterous consequences! One way I "quality check" any new physician I see is to watch how he documents patient encounters...I only keep the docs who dictate their note IMMEDIATELY following our contact....
and this WILL catch up with them sooner or later....testifying in a malpractice case is a horrifying experience...even when your documentation is complete, and accurate...lawyers LOVE doc's like that!
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