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Respected Contributor
Posts: 2,301
Registered: ‎03-16-2010

unexpected details in medical records

My PCP group has a patient portal. I was getting some records together to see a specialist and in the process pulled up my medical notes. I was surprised to read how casual conversations with my doc made it into my permanent records. There was nothing objectionable but interesting.

 

We were just talking about exercise and I said (among other things) that I used Pilates. So in my records it says "patient says that she uses Pilates." I had expressed displeasure in a specialist that I had seen and my comments were in my "visit report."

 

And then I noticed that ALL my records are not included in the portal. In reviewing one of my lab/path reports the heading of the paper copy says "not inclulded in patient portal."

 

Anyway I thought this was interesting.

Honored Contributor
Posts: 17,892
Registered: ‎07-03-2013

Re: unexpected details in medical records

I've noticed this too.  It almost makes you scared to say anything unrelated to the visit, because it's now part of your permanent record.

 

I had two Dr appts a couple weeks ago.  Went to one and thought it went well.  Next day went to the other and the Dr told me about some of the notes from the day before.  They weren't bad, but the Dr the day before hadn't talked about this topic he put in my permanent record.  It would have been nice to have talked about it.

 

I can only see limited things in my portal.

Valued Contributor
Posts: 903
Registered: ‎03-09-2010

Re: unexpected details in medical records

I'm not sure why doctors have "patient portals."  They expect us to update all of our info but they very rarely, in my case, update the results or dates of my visits, tests, and procedures.   Half the time I don't think the doctors even read what we have put into our information.

Honored Contributor
Posts: 15,305
Registered: ‎03-11-2010

Re: unexpected details in medical records

to me it is just one more userid/password to remember.

 

I have one that I created for a yearly appointment for which I get an email but it DOES NOT GIVE ME THE TIME OF THE APPT.  So I called them about it and they told me they know but can't do anything about it.  What a useless POS.

 

I won't do anymore. 

I also think they more one create the more vulnerable you are for data infiltration etc

Trusted Contributor
Posts: 1,069
Registered: ‎03-09-2010

Re: unexpected details in medical records

My Office visit conversations do not bother me.  However, I have been battling ovarian cancer for five years and have had numerous surgeries.  I went back and read surgical notes from procedures done this year to discover I was in respiratory failure during the last two surgeries.  I also discovered comments by the last surgeon that my cancer seems to have spread.  No one told me about the last two points. When I called the involved doctors, it seems they decided that I did not " need to be worried."

Valued Contributor
Posts: 3,861
Registered: ‎03-09-2010

Re: unexpected details in medical records

I agree, granddi, that really looking through these patients records, is really interesting.

Esteemed Contributor
Posts: 5,820
Registered: ‎04-20-2013

Re: unexpected details in medical records

Progress notes with any physician include your conversations because it may be significant to your care, cue a doctor's memory about your visit but it protects  your doctor re to medical malpractice and you as well .  Say you come down with colon cancer and the doctor recommended  you to have a diagnostic or screening colonoscopy during a visit and you refuse the procedure.  The first question in a malpractice lawsuit would be, what did your doctor do for you?   As far as protecting the patient, say you were in a car accident, seen at a hospital and released.  There are records that can be retrieved but often, the patient's account of what happened in detail is absent or in cases of domestic/child abuse, there may be statements made that are significant, so the notes will support a claim or protect or help the patient in some way.  A host of things may come up in a conversation with a doctor that may seem trivial but later, quite important or vital.   So patient history and visits are an important, legal  and necessary part of your records.  

Honored Contributor
Posts: 35,149
Registered: ‎08-23-2010

Re: unexpected details in medical records

ANYTHING you say can be written into your records, so never assume that your conversations are personal or off the record.   

 

I'm not sure why anyone would be surprised at this .....

Esteemed Contributor
Posts: 7,652
Registered: ‎03-09-2010

Re: unexpected details in medical records

@KailaS, it would upset me that my doctor hadn't shared this information.  These are both things I would want to know.  Hope you'real doing ok.  LM

Honored Contributor
Posts: 12,997
Registered: ‎03-25-2012

Re: unexpected details in medical records

A whole new way to "CYA."

Formerly Ford1224
We must always take sides. Neutrality helps the oppressor, never the victim. Silence encourages the tormentor, never the tormented. Elie Wiesel 1986