MemberOctober 2, 2016 at 9:47 pm
Inaccurate medical records
Thanks for looking at the notes. Here is the problem, these are the entire notes from this visit. On the last page it clearly states by the Dr. that he has dictated the progress notes from the visit and signed off on this. Which included going over my medical history, how and when the hernia occurred plus a physical exam of the inguinal area which the Dr. could not find a hernia and asked for me to point out the location of the hernia, which was at the site of the open appendix surgery. I kept asking for his progress notes and was told repeatedly to contact medical records who could not find any notes. Finally I found out he had later stated that it was possible that none were ever taken. The hospital stated that my care was standard and acceptable! I would be more than happy to forward my 2nd and third exam histories, again he did not enter in any progress notes. So I had surgery with no progress notes. Nowhere in my history states which side the hernia is on, type of hernia, his physical findings of inguinal exam, or agreed upon treatment plan. Not sure how a resident could review a patients history before assisting in a surgery and not going to the surgeon and asking about the patients with no medical history.