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  • Inaccurate medical records

    Posted by MO on September 13, 2016 at 2:28 pm

    I would understand if the administrators of this forum considered this off topic and took it down. Although I am so grateful for the compassion and expertise of the last specialist, I need to find a way to tactfully write to him and list about 10 items in his report that are incorrect. Maybe the surgical resident who was in the room wrote the notes. This is so awkward that I am seriously considering asking all future doctors for permission for me to record encounters.

    About the next specialist, if I see him before last record fixed, how do they know I am telling the truth?

    Does anyone here have a recommended forum for this topic?

    drtowfigh replied 7 years, 5 months ago 3 Members · 4 Replies
  • 4 Replies
  • Beenthere

    Member
    October 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.

  • drtowfigh

    Moderator
    October 1, 2016 at 5:09 pm

    Inaccurate medical records

    The notes you posted are just one part of your records–the least important. The actual progress note is most important

  • Beenthere

    Member
    September 14, 2016 at 3:05 pm

    Inaccurate medical records

    This is interesting since I was going to write a note asking if I could post my medical history since most of it is not in the history or made up the Dr. and his staff and when I complained the hospital told me to write a correct history but they could reject it and file it in my medical history. They also stated that this was standard and acceptable. I am reposting my first exam notes from this Dr. . Let me ask the Doctors on this forum. If I was scheduled for surgery and my surgeon was unable to perform it and you were asked to step in to do it, would you do it after reviewing the attached records?

    Again now I know better get copies of you medical exam records before surgery.

    Would it be acceptable to post my medical history with the names of the Dr., staff and hospital to make the public aware of what type of care they might be getting? Would the readers of the forum be interested in seeing them?

  • drtowfigh

    Moderator
    September 13, 2016 at 4:03 pm

    Inaccurate medical records

    We surgeons are also frustrated by inadequate or incorrect documentation. You are not alone.
    In important situations, we can call the surgeon to clarify the records. In the best case scenario the medical record may also be corrected. It’s rare.

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