Community Chat

[ivey]

Years ago, my doctor recommended me to a neurosurgeon for my neck. He seemed qualified. When I went back for a follow up, I asked for a copy of his findings. Someone in his office had taken someone else's summative report, whited out--not corrected on a computer, the name and changed it to mine.

In several places, it referred to lumbar region when I had gone for a cervical check up. AND it referred about half the time to him instead of her. It had my age wrong, etc.

When he was talking to me, he had managed to initial a couple of wrong things. And of course, there was the obligatory "dictated but not read" remark at the bottom.

I happened to teach in a specialized medical school, and I used it for years as an example. The students were appalled. I would never refer anyone to that doctor. He might operate on the wrong part!

[dooBdoo]

On 6/13/2014 skuggles said:

On 6/13/2014 dooBdoo said:

On 6/13/2014 tansy said: Having transcribed for years, shorty, some doctors have a boiler plate patient note that they dictate. That comment might very well be on every patient note he dictates concerning high blood pressure.

I transcribed medical records in my early days just out of college. You're right about the boiler plate notes. Shorty, this one wouldn't even raise an eyebrow for another physician to read. Mind you, I'm not advocating errors in medical records and not saying there haven't been serious ones. Fortunately, when you look at the incredible volume of documentation the errors are a miraculously small percentage.

I'm not sure exactly how you would know that there are or aren't errors, when you are transcribing, and you weren't present for the exam.

I think I understand what you're saying. I was speaking from the perspective of having done systematic internal reviews in hospitals later in my career in medical centers. As with just about everything we try to measure, document, and keep watch on, there's no way to know exactly every instance of an error. In the settings in which I've worked, I did see vigilance to maintain high quality.

[bikerbabe]

Shorty I don't believe this was a judgement of you. I agree this sounds like a boilerplate statement that is part of notes for anyone with high bp.

[skuggles]

On 6/13/2014 dooBdoo said:

On 6/13/2014 skuggles said:

On 6/13/2014 dooBdoo said:

On 6/13/2014 tansy said: Having transcribed for years, shorty, some doctors have a boiler plate patient note that they dictate. That comment might very well be on every patient note he dictates concerning high blood pressure.

I transcribed medical records in my early days just out of college. You're right about the boiler plate notes. Shorty, this one wouldn't even raise an eyebrow for another physician to read. Mind you, I'm not advocating errors in medical records and not saying there haven't been serious ones. Fortunately, when you look at the incredible volume of documentation the errors are a miraculously small percentage.

I'm not sure exactly how you would know that there are or aren't errors, when you are transcribing, and you weren't present for the exam.

I think I understand what you're saying. I was speaking from the perspective of having done systematic internal reviews in hospitals later in my career in medical centers. As with just about everything we try to measure, document, and keep watch on, there's no way to know exactly every instance of an error. In the settings in which I've worked, I did see vigilance to maintain high quality.

Thank you. I believe in most cases, there probably is "vigilance to maintain high quality". I think the climate is changing because of so many constraints too detailed for this discussion, and it has become easier to overlook the person behind the condition, and practice a defensive medicine where these little "errors" crop up, that go unchecked. There are judgements made about patients. The medical record is no place for them. I think this poster recognized the subtle negative inference and she doesn't like it. It shouldn't be there, and she shouldn't have to practice defensive medical record correcting as a patient. I agree most docs wouldn't give that a second thought, but can you measure any influence it may have on their way of seeing the patient? I don't think so. It doesn't rise to the level of malpractice or anything like that, but I think it requires more attention, education, and vigilance.

[tansy]

On 6/13/2014 skuggles said:

On 6/13/2014 dooBdoo said:

On 6/13/2014 skuggles said:

On 6/13/2014 dooBdoo said:

On 6/13/2014 tansy said: Having transcribed for years, shorty, some doctors have a boiler plate patient note that they dictate. That comment might very well be on every patient note he dictates concerning high blood pressure.

I transcribed medical records in my early days just out of college. You're right about the boiler plate notes. Shorty, this one wouldn't even raise an eyebrow for another physician to read. Mind you, I'm not advocating errors in medical records and not saying there haven't been serious ones. Fortunately, when you look at the incredible volume of documentation the errors are a miraculously small percentage.

I'm not sure exactly how you would know that there are or aren't errors, when you are transcribing, and you weren't present for the exam.

I think I understand what you're saying. I was speaking from the perspective of having done systematic internal reviews in hospitals later in my career in medical centers. As with just about everything we try to measure, document, and keep watch on, there's no way to know exactly every instance of an error. In the settings in which I've worked, I did see vigilance to maintain high quality.

Thank you. I believe in most cases, there probably is "vigilance to maintain high quality". I think the climate is changing because of so many constraints too detailed for this discussion, and it has become easier to overlook the person behind the condition, and practice a defensive medicine where these little "errors" crop up, that go unchecked. There are judgements made about patients. The medical record is no place for them. I think this poster recognized the subtle negative inference and she doesn't like it. It shouldn't be there, and she shouldn't have to practice defensive medical record correcting as a patient. I agree most docs wouldn't give that a second thought, but can you measure any influence it may have on their way of seeing the patient? I don't think so. It doesn't rise to the level of malpractice or anything like that, but I think it requires more attention, education, and vigilance.

It is highly unlikely, like not going to happen, that the note would be returned to the original doctor to be changed.

[2000survivor]

I had a left side radical nephrectomy, (left kidney, lymph nodes, fat bed etc removed) in 2000. The surgeon and others involved at the time documented correct, left side. A few years down the road someone documented it the right side. Took quite a bit to get this straightened out, even with the surgeons documentation.

[september]

I'm sure a lot of mistakes get made, and get passed on in a patient's medical records. My husband had surgery a few months ago, and I was reading notes in his chart.

They stated that he'd had a heart attack in the past, and that he was on a medication for asthma. Both of these notes were wrong, and I called it to the Dr's attention. I doubt that corrections got made. This Dr. was an opthalmologist, and wasn't concerned with mistakes that weren't relevant to his field.

[skuggles]

On 6/13/2014 tansy said:

On 6/13/2014 skuggles said:

On 6/13/2014 dooBdoo said:

On 6/13/2014 skuggles said:On 6/13/2014 dooBdoo said:

On 6/13/2014 tansy said:It is highly unlikely, like not going to happen, that the note would be returned to the original doctor to be changed.

Even if the patient takes it directly to the doctor.? You'd be surprised at how doctors are being advised to admit mistakes now. I think the doctor, if questioned by the patient, and if he/she has any integrity, would be glad to admit the "error" ... and agree to correct it. Otherwise ... I think I'd move on to a new doctor, personally.

Maybe institutions would not bother to take action, but I hope an individual would. If not, I have even greater concern. If the attitudes toward accuracy on the small stuff, yet still a part of a legal record, are so cavalier, this is very concerning

[tansy]

Skuggles, if it were a major mistake 2000survivor stated above, I think you would be able to get it fixed with a concerted effort on your part. This particular comment would not be fixed IMO. Another doctor cannot change this doctor's remarks.

[Shorty2U]

From the OP. Well once again I learned something new. You are all very informative! Thank you for the replies! I usually don't even read the read outs but try to save the later ones until I get a pile more then I shred the old ones. I also noticed my pain team has down how I sit on the chair, how I speak (as in coherent..lol) and all this stuff I never noticed before (besides my meds, stats, pain level, and so on).