SIGforum.com Main Page The Lounge Stuff on Medical Records that I don't like/Agree with. Is this normal/can it be changed?
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| JOIN, or DIE |
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? | ||
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| Member |
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. | |||
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| Member |
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 ! | |||
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W07VH5 |
Who's going to look at your medical records? They're private. | |||
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E Pluribus Unum |
Ummm...insurance companies??? | |||
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| Member |
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. | |||
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| Little ray of sunshine  |
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. | |||
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| Member |
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 | |||
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| Little ray of sunshine |
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. | |||
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| SIGforum Official Eye Doc  |
Good one. | |||
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Age Quod Agis |
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." Alfred Hornik, Sunday, December 2, 1945 to his family, on his continuing duty to others for surviving WW II. | |||
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| SIGforum Official Eye Doc |
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. | |||
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| Needs a check up from the neck up  |
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. __________________________ 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 | |||
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Member |
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." | |||
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| Too old to run, too mean to quit! |
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 There has never been an occasion where a people gave up their weapons in the interest of peace that didn't end in their massacre. (Louis L'Amour) "To compel a man to furnish contributions of money for the propagation of opinions which he disbelieves and abhors, is sinful and tyrannical. " -Thomas Jefferson "America is great because she is good. If America ceases to be good, America will cease to be great." Alexis de Tocqueville FBHO!!! The Idaho Elk Hunter | |||
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Info Guru |
Since it appears that several serious answers have been offered...You all do know that this was covered in a Seinfeld episode??  “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 | |||
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Oriental Redneck |
Absolutely this. Q | |||
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| Member |
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. | |||
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| Member |
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. | |||
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Seeker of Clarity |
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).  | |||
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