My records have major mistakes
By Barby Ingle
(excerpt from The Pain Code Book)
Your medical record is comprised of all information generated during your treatment with all healthcare providers. The providers keep track of many aspects of your treatment, including personal, financial, social, and medical information. Many providers are using written forms and notes, but over the past few years, there are great electronic medical record keeping programs that are coming to the market. I am seeing more and more the providers coming in with their laptop and all of my information is in my electronic file. It is important to know what is in your record.
After you order and receive your copies, go through them and check for errors. Check everything because these records are used as a means of communication between your healthcare professionals, hospital staff, physical therapist, etc. They are a legal documentation of the care you have received, a verification of services and many insurance companies request them in chronic care cases to decide on approval of treatment options. The records also serve as basic data for research and education purposes.
It is important to correct mistakes you find on your records. Once a doctor enters the records they are not supposed to change them in many cases. But that doesn’t mean you can do something about the mistakes. When I find mistakes I create a letter and form to the provider to be attached to my medical record. So, if another provider, lawyer (in the case of WC or personal injury) receives a copy, they see the corrections and don’t get thrown off by mistakes that lead to a misdiagnosis, confusion, or delay in proper and timely care.
Sample letter
Dear Dr. XYZ,
Thank you so much for evaluating me on March 15, 2015. It means a lot to me to have you on my medical team. Things are progressing thanks to the hard work you and your office staff have put in to making the treatment you got/are getting a possibility for me.
Update on your condition/treatment since last visit. (example: To date I have done my chest x-ray, echo-cardio gram, blood testing. This week I will be completing my Neuro-Psychological evaluation and insertion of my Portacath. My plan is to then take the appropriate time to heal from the Portacath surgery and then complete XYZ. I will have my Portacath placed at which hospital on June 30, 2015. My future Portacath monthly care will take place at HHH.)
I have had a chance to look over your medical record notes from my recent examination. I understand that this is your assessment of the examination that took place and it is already written into my file. I would like to take this opportunity to have included in this record the attached response to make sure that we have included all pertinent information.
Please feel free to contact me to discuss this. Otherwise, I will see you in a few weeks at our next appointment. I am really looking forward to working with you. I thank you so much for all of your help, patience, and support as I complete this process.
Sincerely,
Your name
Your contact info
Corrections to Dr. XYZ records dated 4/15/2015
Page 1
Section – PRESENT ILLNESS INFORMATION
Report States: Chief Complaint: Facial, neck, head, abdominal, back, buttocks, leg, hip, foot pain
Patients Correction: Chief Complaint: Facial, neck, head, abdominal, back, buttocks, chest, both legs, both feet, pelvic pain, both arms, both hands, thoracic pain, full body RSD/CRPS, Graves
Page 2
Section- PAST, FAMILY AND SOCIAL HISTORY
Report States: Med Allergies: Keflex: Unknown, unspecified
Patients Correction: Med Allergies: Med Allergies: Keflex: Diarrhea; dizziness; headache; indigestion; joint pain; stomach pain; tiredness, rash; hives; itching; difficulty breathing; tightness in the chest; confusion; dark urine, Erythromycin, hives, diarrhea, vomiting, Trazadone: fast, irregular heartbeat, feeling faint or lightheaded, hallucinations, mood changes, trembling, headache, nausea, vomiting, unusually weak or tired
Report States: Non-Med Allergies: Food Allergies or intolerance: None
Contact allergies: none
Contrast agent (dye) allergies: none
Patients Correction: Non-Med Allergies: Food Allergies or intolerance: None
Contact allergies: none
Contrast agent (dye) allergies: none
Tape Adhesive- skin blistering and rash
Report States: Surgeries and Hosp: Problems with anesthesia: none
Previous surgery: none
Previous non-surgical hospitalizations: none
Patients Correction: Surgeries and Hosp: Problems with anesthesia: Nausea
Previous surgery:
|
7/1999 |
Jaw Surgery |
|
8/2000 |
Straighten Deviated Septum |
|
3/2001 |
Ganglion Nerve Block (series of 2) |
|
4/2003 |
Epidural Nerve Block (series of 3) |
|
7/2009 |
Appendectomy |
|
2010 |
Arthroscopic Meniscus Repair, Right Knee |
|
2/8/2012 |
Hysterectomy; endometriosis |
Previous non-surgical hospitalizations: none
Section – OBJECTIVE
Report States: Construction (final comment): Patient arrived at XYZ today ambulatory, without the use of any support equipment. Patient was accompanied by: Adult Female
Patients Correction: Construction: (final comment): Patient arrived at XYZ today ambulatory, with the use of any support equipment (cane). Patient was accompanied by: Her Husband and Adult Female.
Report States: Musculoskeletal: Right upper extremity: normal inspection/palpation, ROM, muscle strength and tone, and stability.
Left upper extremity: normal inspection/palpation, ROM, muscle strength and tone, and stability.
Right lower extremity: normal inspection/palpation, ROM, muscle strength and tone, and stability.
Left lower extremity: normal inspection/palpation, ROM, muscle strength and tone, and stability.
Patients Correction: Musculoskeletal: Right upper extremity: abnormal inspection/palpation, ROM, muscle strength and tone, and stability.
Left upper extremity: abnormal inspection/palpation, ROM, muscle strength and tone, and stability.
Right lower extremity: abnormal inspection/palpation, ROM, muscle strength and tone, and stability.
Left lower extremity: abnormal inspection/palpation, ROM, muscle strength and tone, and stability
Page 3
Report States: Skin: Normal skin, subcutaneous tissue, scalp, hair, eccrine and apocrine glands.
Patients Correction: Skin: Abnormal: skin, eccrine and apocrine glands, Blanching, Rash, Excess sweating and Skin Ulcers present. Normal: subcutaneous tissue, scalp, hair
Report States: Neurologic: Gait: Normal
Station: Normal
Patients Correction: Neurologic: Gait: Abnormal
Station: Abnormal
Section- PLAN
Report States: Comments: Patient checked out of XYZ today ambulatory, without the use of any support equipment. All questions were answered and patient verbalized understanding of today’s visit, including treatment and orders. Patient was accompanied by: Adult Female.
Patients Correction: Comments: Patient checked out of XYZ today ambulatory with the use of any support equipment (cane). All questions were answered and patient verbalized understanding of today’s visit, including treatment and orders. Patient was accompanied by: Her Husband and Adult Female.
