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Stuff on Medical Records that I don't like/Agree with. Is this normal/can it be changed? Login/Join 
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Had a chance to look at some medical records of myself. There is a statement, something to the effect of "patient denies Cocaine use". I'm concerned that first, it makes it look like they had suspected me of it and second, that the statement is standing relatively alone with no context. There is another thing about smoking that isn't correctly stated and placed without context. I'm concerned that if someone where to look at that, it would give them the wrong impression of me. Anybody deal with this before?
 
Posts: 3569 | Registered: February 25, 2010Reply With QuoteReport This Post
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I would guess that there was some finding that could be associated with cocaine use, but could also be explained by other conditions that needed to be explored. Don't read to much into the tone of "denies". That's just typical charting language.
 
Posts: 8944 | Location: The Red part of Minnesota | Registered: October 06, 2002Reply With QuoteReport This Post
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I have a similar question. I had a Physical for the first time in a decade plus last September at my wife's urging. Blood panel, the works. Doc tells me during the meeting that she wants me on diabetes meds asap. I say whoa whoa whoa. Lets talk first. I can quit the 1-2 liters a day of Coca Cola. I can quit eating starchy rice and egg noodles with a slab of butter on them before bed. Give me 90 days. So I re-test the blood in 90 days and the sugar level has gone through the floor and cholesterol is within acceptable levels and I lost 10 pounds. She says ok. So it's your diet no meds but watch out. So I have had no soft or sugary drink in ~10 months. Water tea cofffe or milk with dinner or occasional beer. No soda. Cut my noodles and rice way way down. So I'm still on their list as a diabetic and the office girls call me asking all the time if I'm doing this or that. I'm like get it strait. Doc never gave me a Rx. And Aetna those bastards. I get mailers all the time for keeping my diabetes u see control. Wtf. I'm in their system as a basket case now. I'd be better off if I had admitted to smoking a carton a day and having unprotected sex in Haiti.

So how do I get my record straitene out !
 
Posts: 4737 | Location: Florida Panhandle  | Registered: November 23, 2008Reply With QuoteReport This Post
W07VH5
Picture of mark123
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Who's going to look at your medical records? They're private.
 
Posts: 45331 | Location: Pennsyltucky | Registered: December 05, 2001Reply With QuoteReport This Post
E Pluribus Unum
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quote:
Originally posted by mark123:
Who's going to look at your medical records? They're private.

Ummm...insurance companies???
 
Posts: 1407 | Location: Minnesota | Registered: March 05, 2009Reply With QuoteReport This Post
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quote:
Originally posted by ElToro: So I re-test the blood in 90 days and the sugar level has gone through the floor and cholesterol is within acceptable levels and I lost 10 pounds.


Whether the diagnosis is still accurate would depend on the actual A1c regardless of your good progress. I'm sure they've got you on the watch list due to the difficulty staying on a highly restrictive diet. Many people will end up on meds after a while. Unfortunately, you now have the dreaded "pre-existing condition" that we have debated in the health care reform thread.
 
Posts: 8944 | Location: The Red part of Minnesota | Registered: October 06, 2002Reply With QuoteReport This Post
Little ray
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Picture of jhe888
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That is the way doctors write in charts.

Doc, my heat is racing.

Have you used any cocaine?

No.

Writes: Patient denies cocaine use.

That is all it is. The doctor doesn't know that you did or didn't use cocaine, he only knows that you said you didn't.

Relax - that cocaine will make you paranoid.




The fish is mute, expressionless. The fish doesn't think because the fish knows everything.
 
Posts: 53118 | Location: Texas | Registered: February 10, 2004Reply With QuoteReport This Post
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quote:
Originally posted by ElToro:
I have a similar question. I had a Physical for the first time in a decade plus last September at my wife's urging. Blood panel, the works. Doc tells me during the meeting that she wants me on diabetes meds asap. I say whoa whoa whoa. Lets talk first. I can quit the 1-2 liters a day of Coca Cola. I can quit eating starchy rice and egg noodles with a slab of butter on them before bed. Give me 90 days. So I re-test the blood in 90 days and the sugar level has gone through the floor and cholesterol is within acceptable levels and I lost 10 pounds. She says ok. So it's your diet no meds but watch out. So I have had no soft or sugary drink in ~10 months. Water tea cofffe or milk with dinner or occasional beer. No soda. Cut my noodles and rice way way down. So I'm still on their list as a diabetic and the office girls call me asking all the time if I'm doing this or that. I'm like get it strait. Doc never gave me a Rx. And Aetna those bastards. I get mailers all the time for keeping my diabetes u see control. Wtf. I'm in their system as a basket case now. I'd be better off if I had admitted to smoking a carton a day and having unprotected sex in Haiti.

So how do I get my record straitene out !


The butter you mentioned is not a problem, within reason. It does give carb specific satiety (lack of hunger), so no need to avoid butter.


-c1steve
 
Posts: 4041 | Location: West coast | Registered: March 31, 2012Reply With QuoteReport This Post
Little ray
of sunshine
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quote:
Originally posted by JRC:
quote:
Originally posted by mark123:
Who's going to look at your medical records? They're private.

Ummm...insurance companies???


Well . . . they are entitled to know how your health is, aren't they? They are insuring your healthcare costs. It is the bargain we make with them.




The fish is mute, expressionless. The fish doesn't think because the fish knows everything.
 
Posts: 53118 | Location: Texas | Registered: February 10, 2004Reply With QuoteReport This Post
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quote:
Originally posted by jhe888:
That is the way doctors write in charts.

Doc, my heat is racing.

Have you used any cocaine?

No.

Writes: Patient denies cocaine use.

That is all it is. The doctor doesn't know that you did or didn't use cocaine, he only knows that you said you didn't.

Relax - that cocaine will make you paranoid.


Good one.
 
Posts: 2927 | Location: (Occupied) Northern Minnesota | Registered: June 24, 2003Reply With QuoteReport This Post
Age Quod Agis
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jhe is the resident expert on cocaine. And hookers...



"I vowed to myself to fight against evil more completely and more wholeheartedly than I ever did before. . . . That’s the only way to pay back part of that vast debt, to live up to and try to fulfill that tremendous obligation."

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Posts: 12748 | Location: Central Florida | Registered: November 02, 2008Reply With QuoteReport This Post
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quote:
Originally posted by EmpireState:
Had a chance to look at some medical records of myself. There is a statement, something to the effect of "patient denies Cocaine use". I'm concerned that first, it makes it look like they had suspected me of it and second, that the statement is standing relatively alone with no context. There is another thing about smoking that isn't correctly stated and placed without context. I'm concerned that if someone where to look at that, it would give them the wrong impression of me. Anybody deal with this before?


Chart addendum: Patient questions authority. Displays paranoid tendencies. States care providers incorrect. Believes others are out to get him. Recommend 90-day involuntary evaluation/monitoring at Shady Hills Care Facilty. Will get orders to care and apprehension team ASAP.
 
Posts: 2927 | Location: (Occupied) Northern Minnesota | Registered: June 24, 2003Reply With QuoteReport This Post
Needs a check up
from the neck up
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PS dont ask the DR to change the chart, that will just end up with
PT called and asked to remove diabetes from him chart/still isn't taking diabetes meds

Then your double fucked.
You can, if you so desire write a letter of explanation and have it added to the chart.

Something along the lines of:
I have never done cocaine and DR agrees that diet change controlled insulin issues and has not RXed meds for diabetes.

More often than not, I would avoid writing the letter, it makes you seem like a trouble case.
Now if you get denied coverage or something a letter from the DR might be more appropriate.


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The entire reason for the Second Amendment is not for hunting, it’s not for target shooting … it’s there so that you and I can protect our homes and our children and and our families and our lives. And it’s also there as fundamental check on government tyranny. Sen Ted Cruz
 
Posts: 5131 | Location: Boca Raton, FL The Gunshine State | Registered: July 30, 2002Reply With QuoteReport This Post
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Wait till they get to the next question:
"Have you stopped beating your wife?"



"I started out with nothin' and I still got most of it left."
 
Posts: 741 | Location: SW Ohio | Registered: February 17, 2007Reply With QuoteReport This Post
Too old to run,
too mean to quit!
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quote:
Originally posted by JRC:
quote:
Originally posted by mark123:
Who's going to look at your medical records? They're private.

Ummm...insurance companies???


This!!

Frankly, I would tell them to either show the medical proof of their statement on my records or will change doctors!. I would discuss it with the doctor and tell him to make sure they remove it. Given a few days to correct it, I would inspect my records to see that it was gone.

I has an incident with a previous doctor, years ago, about them not showing me my records. They wanted 25 bucks to see them. Told them they were my records, and I not only wanted to see them, I wanted a copy. Conversation got spirited, but they did what I wanted.

Bigger question might be, how much of that is in the gubbermint hands? AIR, the feds get copies of a LOT of medical records, simply as a matter of course. I do remember from some time ago about a small shit storm over the feds collecting our medical info.


Elk

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FBHO!!!



The Idaho Elk Hunter
 
Posts: 25640 | Location: Virginia | Registered: December 16, 2001Reply With QuoteReport This Post
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Since it appears that several serious answers have been offered...You all do know that this was covered in a Seinfeld episode?? Big Grin




“Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passions, they cannot alter the state of facts and evidence.”
- John Adams
 
Posts: 29408 | Location: In the red hinterlands of Deep Blue VA | Registered: June 29, 2001Reply With QuoteReport This Post
Oriental Redneck
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quote:
Originally posted by MNSIG:
... Don't read to much into the tone of "denies". That's just typical charting language.

Absolutely this.


Q






 
Posts: 26205 | Location: TEXAS | Registered: September 04, 2008Reply With QuoteReport This Post
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quote:
More often than not, I would avoid writing the letter, it makes you seem like a trouble case.
Now if you get denied coverage or something a letter from the DR might be more appropriate.



I agree, denies cocaine usage is typical charting. The electronic health record often requires responses to these questions and it is then typed into your chart.

Correcting things in the Medical Record are best brought up in a FACE TO FACE meeting with your doctor. Allergies to medications, past surgeries, and past diagnoses should be reviewed and then corrected if there are errors. Being that transcription services are at times poor, there is room for error.
 
Posts: 17177 | Location: Stuck at home | Registered: January 02, 2015Reply With QuoteReport This Post
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Originally posted by Elk Hunter: I would discuss it with the doctor and tell him to make sure they remove it. Given a few days to correct it, I would inspect my records to see that it was gone.


There is no legal way to actually remove an entry from a medical record. It can be revised or noted with a single strike, but must remain legible. That's on paper. Electronic records generally cannot be altered at all. Either way, that entry isn't going anywhere.
 
Posts: 8944 | Location: The Red part of Minnesota | Registered: October 06, 2002Reply With QuoteReport This Post
Seeker of Clarity
Picture of r0gue
posted Hide Post
quote:
Originally posted by jhe888:
That is the way doctors write in charts.

Doc, my heat is racing.

Have you used any cocaine?

No.

Writes: Patient denies cocaine use.

That is all it is. The doctor doesn't know that you did or didn't use cocaine, he only knows that you said you didn't.

Relax - that cocaine will make you paranoid.


This is true. And also, insurance companies do not get to look at your medical record. They get claims filed, and on rare occasion they do a chart review associated with the claim to verify medical necessity. That's it. HIPAA minimum necessary access standards require they only get relevant data, and you have a right to demand audit of any and all access to your PHI (Protected Health Information).




 
Posts: 11355 | Registered: August 02, 2004Reply With QuoteReport This Post
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