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Esteemed Contributor
Posts: 6,247
Registered: ‎11-15-2011

Re: unexpected details in medical records

Unfortunately, that has become necessary in today's society!  CYA

Respected Contributor
Posts: 2,287
Registered: ‎03-16-2010

Re: unexpected details in medical records

It was not a total surprise. It is CYA. I thought others should know.

Esteemed Contributor
Posts: 6,823
Registered: ‎03-11-2010

Re: unexpected details in medical records

It seems I am listed on three portals.  My primary doctors office signed me up and he never spends time giving information.  So I read a blank page.  Why bother.  

 

 

Honored Contributor
Posts: 13,890
Registered: ‎03-11-2010

Re: unexpected details in medical records

[ Edited ]

I have got copies of medical records from previous doctors or doctors that have retired. I looked through them to see when I asked about this or that to find the info is not in my records. I'm hypothyroid & also found it listed as me being hyperthyroid in some. Not good IMO. When I have questions to ask the doctor I ask him if his recorder is still on. I tell him this is between me & you & I don't want it in my records.

Respected Contributor
Posts: 2,287
Registered: ‎03-16-2010

Re: unexpected details in medical records

So do physicians routinely record (audio) patient visits?

 

Many who have read this topic just don't care one way or another about this subject. Many think,  it is what it is and nothing can or should be done. It is only when you find out that your permanent medical records contain errors, omissions or contain sensitive information not related to your helath or information that should have been discolosed to you,  that I think we as medical consumers should be concerned. 

 

For the person that said he/she looked on line at their records and the pages were blank, you should ask why are your records not available. Your records are not blank, you just don't have access to them. 

 

thanks to all who have given input to this topic.

Honored Contributor
Posts: 35,072
Registered: ‎08-23-2010

Re: unexpected details in medical records

[ Edited ]

Things get released and hacked all the time ..... so I don't know how I'd feel if the MD wanted to record our conversations .... just not sure I'd be comfortable with that.

Honored Contributor
Posts: 13,890
Registered: ‎03-11-2010

Re: unexpected details in medical records


@Tinkrbl44 wrote:

Things get released and hacked all the time ..... so I don't know how I'd feel if th4e MD wanted to record our conversations .... just not sure I'd be comfortable with that.


 

I know the doctors I have seen record your conversation. I have seen them reach in their pocket to turn it on/off. I have also seen them talking into it leaving notes as I go back up front. This is how the info gets transcribed into your medical records.

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

Re: unexpected details in medical records

When my GP gave out the passwords to the online portal I hopped right on and checked out my records. The first thing I noticed is that it said something about me having Celiac disease. Which is clearly a mistake as I DO NOT have this. Interesting.

Respected Contributor
Posts: 2,245
Registered: ‎04-16-2010

Re: unexpected details in medical records


@Greenhouse wrote:

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.  


 

Excellent explanation and comments, @Stray!!! The same chronic complainers, however, would rather lob accusations and insults towards people in the medical field, especially physicians.

Honored Contributor
Posts: 25,929
Registered: ‎03-09-2010

Re: unexpected details in medical records

Our doctors patient portal - he types on it as we are talking and then before I leave he will show it to me and ask if I have anything to add or any questions. He does not write any opinions on it - just the facts. If I am ok with it then I "sign" it using my password. Usually he puts that he reviewed my labs and if anything on them is bad we discuss it and he puts down what his plan is and what he told me to do - ie: change a Rx or a diet change etc. In other words , when I leave his office I know exactly everything that is on the patient portal.