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Originally posted by 12131:

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Originally posted by MNSIG:
... Don't read to much into the tone of "denies". That's just typical charting language.

Absolutely this.

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Originally posted by EmpireState:It was for heart issues/heart attack at a relatively young age. I remember them asking me in the ER about drugs, which I don't do. Just rubbed me the wrong way reading that today, the way is was written. Instead of "patient denies cocaine use", I would have preferred "no signs of drug use", but I'm not in the field.

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Originally posted by bcereuss:

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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.

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Originally posted by EmpireState:

Thanks for the responses, it makes me feel better that this is normal in the industry. It was for heart issues/heart attack at a relatively young age. I remember them asking me in the ER about drugs, which I don't do. Just rubbed me the wrong way reading that today, the way is was written. Instead of "patient denies cocaine use", I would have preferred "no signs of drug use", but I'm not in the field.

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Originally posted by mrbill345:

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Originally posted by EmpireState:

Thanks for the responses, it makes me feel better that this is normal in the industry. It was for heart issues/heart attack at a relatively young age. I remember them asking me in the ER about drugs, which I don't do. Just rubbed me the wrong way reading that today, the way is was written. Instead of "patient denies cocaine use", I would have preferred "no signs of drug use", but I'm not in the field.

Anyone who presented into my ER with heart issues/heart attack would have been asked specifically about drugs/medications (inhaler abuse, caffeine, etc.) that could cause those issues as well as other risk factors.

As Dr. House says "patients lie" - not all, but many do.

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Originally posted by EmpireState:
Instead of "patient denies cocaine use", I would have preferred "no signs of drug use", but I'm not in the field.

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Originally posted by EmpireState:

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Originally posted by 12131:

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Originally posted by MNSIG:
... Don't read to much into the tone of "denies". That's just typical charting language.

Absolutely this.

Thanks for the responses, it makes me feel better that this is normal in the industry. It was for heart issues/heart attack at a relatively young age. I remember them asking me in the ER about drugs, which I don't do. Just rubbed me the wrong way reading that today, the way is was written. Instead of "patient denies cocaine use", I would have preferred "no signs of drug use", but I'm not in the field.

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Funny, because there was a part later on from a different visit that was more observation of me. Something like clean, dry skin, normal mood, well nourished, speech is good, normal behavior, alert and aware and oriented to surroundings.

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Originally posted by Elk Hunter:
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.