I really need some advice. I have discovered some blatant errors in my medical record that seriously affect my care. I need to know how to address this issue.
Background: In March I was sent to an ortho for upper extremity injury. He sent me to a specialist after three months as I 'wasn't cooperating" and "wasn't healing" as fast as he wanted. The specialist saw me in May and was unwilling to examine me and kept saying 'well your Dr said..." and "according to your Dr." This bothered me and I told him that he was there to fix me not go by what the other Dr said. He *WAS* now my Dr and I needed help. That was not well received.
He was rude and unhelpful telling me that his only option was a surgery that he didn't recommend. I couldn't understand why he was being so cold and unwilling to help. I assumed it was due to my case being w/c (federal DoL). I was devastated as this was supposed to get me help and fix the never ending screaming in my left arm. He was also rude to my advocate and Claims examiner as well. He now wont see me unless I agree to a surgery that he doesn't think will work and has said point blank that at our next visit either I schedule surgery or he closes my case. No, he wont ever touch me.
In mid July, was finally able to find another Dr and get an eval on my wrist (5 months after injury). He has been very thorough, easy to talk to and actually figured out an issue that no one else had addressed. For the first time since February I have experienced some relief. I plan to ask the new guy this Friday to take over my shoulder.
In preparation for my request I have complied all of me records. This is where my concern arises. In the original other's reports there are serious errors. From him talking to my sister (she lives 1000 miles away) to me denying having pain in my neck and wrist (yeah right) or that I sleep well (maybe 3 hours each day) and so so much more. He lists my vitals being taken at a time when I wasn't even there. He references X-rays that were never taken!
There are so many errors that I want to cry... but the ones that bother me the most are when he states during the third visit that I 'suddenly began to complain bitterly of weakness and pain" and "ultimately wanted a work excuse." He also fails to mention the three tears in my MRI report. Even though he attached the report (which clearly states three partial tears). Its unbelievable how wrong all of this is. It does, however, explain why the shoulder specialist wouldn't take me seriously.
So how do I address this to the new Dr and not sound like a raving lunatic? Lord knows I am so very close to being there. I really need this fixed. I need him to look at this fresh and not fall into the mess that the first Dr piled on my case. How do I accomplish this?
I don't know how much longer I can live with this pain. I am now seeing a therapist for depression/anxiety due to this overwhelming situation and constant pain. Ibuprofen and Flexeril aren't doing enough to make life worthwhile. Because of insurance regulations, my PCP cant prescribe meds. Only the attending Dr. can do this. I don't have regular insurance and don't qualify for assistance.
I just don't know if I have enough strength left to endure much more. This will look funny if after 6 months I suddenly ask for pain meds. Why didn't I ask before? I did, he wouldn't comply or even note my requests. My only saving grace is that my husband has been to every single appt with me. But in their eyes he is biased, right? I am at a loss.............
Suggestions would be greatly appreciated. How do I clear up this mess?
Thanks for reading my diatribe.
Daesin
Understanding is the first step to acceptance, and only with acceptance can there be recovery.
As far as your new dr is concerned, I would be honest and straight forward with him. It may or may not get you anywhere. As far as having errors in medical records corrected, I have put a link below that excplain how to do that. But, you will have to deal with the drs that made the errors.
Your Medical Records (See Correcting information)-
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/medicalrecords.html
Your Medical Records (See Correcting information)-
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/medicalrecords.html
Check the link MercyGrace has provided on what you can do. Medical records cannot be changed but you can amend them by correcting whatever you disagree with.
I would not be agreeing to any surgery with the dr that said surgery will not help no more than I would let a dr pressure me into a surgery.
Talk to the dr you like & see if he will take over your care. I would not directly ask this dr for pain meds, instead I would tell him what I am taking is not helping & just ask him to help you with the pain you are having.
I hope you can get some help.
Susie
Moderator Chronic Pain & Psoriasis Forums
I would not be agreeing to any surgery with the dr that said surgery will not help no more than I would let a dr pressure me into a surgery.
Talk to the dr you like & see if he will take over your care. I would not directly ask this dr for pain meds, instead I would tell him what I am taking is not helping & just ask him to help you with the pain you are having.
I hope you can get some help.
Susie
Moderator Chronic Pain & Psoriasis Forums
Mercy, Talon & Straydog,
Thank you for the suggestions. My primary concern at this time isn't correcting the file...I will eventually deal with that. Thank you for the info and link. It will certainly come in handy.
The surgery which the shoulder guy 'offered' was a rotator cuff repair, scraping the arthritis out and shaving off the acromion. All which are needed according to my PCP, the advocate and my PT folks. I wont let him touch me because of his attitude and statements. "If you insist" he would do surgery. No! Not him, not ever!
I don't know how to request that the new guy ignore what is in the file from the previous ortho. The PT reports show there is a problem, the MRI shows several issues but the reports from the Dr are worded in a way which makes me out to be a drug seeker who wants to be off work and only has tendonitis (Oh how I wish that was an accurate depiction of me life). I want this fixed. I want my life back. I want to be able to sweep the kitchen floor, put on a bra or cuddle my grandbabies without crying.
Sadly, being honest did not help me with the shoulder Dr. Though he had an attitude before I walked in the door due to what was in the file from the first ortho. As this is WC I must provide all prior treatment notes before they will evaluate. I am willing to do that I just don't want him to develop a theory before examining my arm himself. Another MRI would be awesome to determine what's going on in the neck and how much more damage happened since I wasn't taken off work for three months in a physical job or given any type of anti-inflammatories. Ibuprofen only gets you so far. The wrist guy has already mentioned a concern over TOS symptoms so I think the mri will happen. He sent me for a EMG/NCV test.
I am not after pain meds per say. Its been almost 6 months and I haven't had any yet so that isn't the end of the world. Yes they would probably make sleeping easier but I would rather be fixed. The shoulder guy originally said he was going to refer me to a PM Dr but then he wouldn't. He wont explain why either. All he did at the last apt was yell at me and tell me that the surgery wouldn't work.
I really feel boxed in. All suggestions are appreciated. My initial thought is as Mercy suggested: be straight forward and hope for the best. Hope that the wrist guy (actually an upper extremities specialist) will look past what the others wrote and see a woman who has a messed up shoulder (and file). I will know Friday I guess.
Fingers, toes, knees, eyes: everything crossed,
Daesin
Understanding is the first step to acceptance, and only with acceptance can there be recovery.
Thank you for the suggestions. My primary concern at this time isn't correcting the file...I will eventually deal with that. Thank you for the info and link. It will certainly come in handy.
The surgery which the shoulder guy 'offered' was a rotator cuff repair, scraping the arthritis out and shaving off the acromion. All which are needed according to my PCP, the advocate and my PT folks. I wont let him touch me because of his attitude and statements. "If you insist" he would do surgery. No! Not him, not ever!
I don't know how to request that the new guy ignore what is in the file from the previous ortho. The PT reports show there is a problem, the MRI shows several issues but the reports from the Dr are worded in a way which makes me out to be a drug seeker who wants to be off work and only has tendonitis (Oh how I wish that was an accurate depiction of me life). I want this fixed. I want my life back. I want to be able to sweep the kitchen floor, put on a bra or cuddle my grandbabies without crying.
Sadly, being honest did not help me with the shoulder Dr. Though he had an attitude before I walked in the door due to what was in the file from the first ortho. As this is WC I must provide all prior treatment notes before they will evaluate. I am willing to do that I just don't want him to develop a theory before examining my arm himself. Another MRI would be awesome to determine what's going on in the neck and how much more damage happened since I wasn't taken off work for three months in a physical job or given any type of anti-inflammatories. Ibuprofen only gets you so far. The wrist guy has already mentioned a concern over TOS symptoms so I think the mri will happen. He sent me for a EMG/NCV test.
I am not after pain meds per say. Its been almost 6 months and I haven't had any yet so that isn't the end of the world. Yes they would probably make sleeping easier but I would rather be fixed. The shoulder guy originally said he was going to refer me to a PM Dr but then he wouldn't. He wont explain why either. All he did at the last apt was yell at me and tell me that the surgery wouldn't work.
I really feel boxed in. All suggestions are appreciated. My initial thought is as Mercy suggested: be straight forward and hope for the best. Hope that the wrist guy (actually an upper extremities specialist) will look past what the others wrote and see a woman who has a messed up shoulder (and file). I will know Friday I guess.
Fingers, toes, knees, eyes: everything crossed,
Daesin
Understanding is the first step to acceptance, and only with acceptance can there be recovery.
Daesin, hopefully with the MRI report & the EMG/NCV, the dr new will pay you more attention than the notes from the other dr. There are some drs who for whatever reason, are not as careful about what they put in patients medical records as they should be. Other drs often know who these drs are and factor that in when viewing patient medical records they wrote.
You may not like this but when dealing with drs honesty is the best policy. You have an MRI that shows the problem with your shoulder, no one can dispute the films/cd of your shoulder. If you try to be too vague the dr may become suspicious of you & you just do not need that. The best way to handle the situation with the other dr is there was a personality conflict & let it go at that.
You have seen the new dr & seem to have have a good relationship with him, but badmouthing another dr to him will only end badly for you. Ask for his help with your shoulder if he does not do shoulders then ask him to refer you to a shoulder dr.. Let him know you have no intention of returning to the other dr. Tell him the dr said surgery would not help & suddenly the dr changed gears saying either schedule the surgery or he was done with you.
Again do not ask this dr for pain medical because if you do, then you will look like a drug seeker. Tell him OTC stuff is not helping at all & now your quality of life is getting bad. If you are having trouble sleeping because of the pain tell him this. Just ask if there is anything he can do or suggest for you to help get the pain down.
As quickly as possible yes, you really need to get your medical records straightened out. These records will follow you from dr to dr..
Good luck.
Take care.
Susie
Moderator Chronic Pain & Psoriasis Forums
You have seen the new dr & seem to have have a good relationship with him, but badmouthing another dr to him will only end badly for you. Ask for his help with your shoulder if he does not do shoulders then ask him to refer you to a shoulder dr.. Let him know you have no intention of returning to the other dr. Tell him the dr said surgery would not help & suddenly the dr changed gears saying either schedule the surgery or he was done with you.
Again do not ask this dr for pain medical because if you do, then you will look like a drug seeker. Tell him OTC stuff is not helping at all & now your quality of life is getting bad. If you are having trouble sleeping because of the pain tell him this. Just ask if there is anything he can do or suggest for you to help get the pain down.
As quickly as possible yes, you really need to get your medical records straightened out. These records will follow you from dr to dr..
Good luck.
Take care.
Susie
Moderator Chronic Pain & Psoriasis Forums
Oh god this can be so upsetting and draining to say the least.
When I got my medical records my Dr had hardly written anything then covered herself with...let's just say...not the truth, it upset me so much.
Then she wrote right leg instead of left, injection in shoulder when it was my neck, right foot pain when it was my left...said I had not gone for appts, that sent me 1/2 wild!! totally not true, she never sent referral's through for me to go to an appt..
Changed Dr's but still at the same medical building, I've never mentioned the other Dr and neither has this one.
Good advice from others.
Good luck, I know how upsetting it is.
When I got my medical records my Dr had hardly written anything then covered herself with...let's just say...not the truth, it upset me so much.
Then she wrote right leg instead of left, injection in shoulder when it was my neck, right foot pain when it was my left...said I had not gone for appts, that sent me 1/2 wild!! totally not true, she never sent referral's through for me to go to an appt..
Changed Dr's but still at the same medical building, I've never mentioned the other Dr and neither has this one.
Good advice from others.
Good luck, I know how upsetting it is.
Drs usually don't know if you see a dr they refer you to. Office staff handle referrals. There are times that the referring dr gets a report back from the dr the patient was referred to but not always.
I absolutely agree that honesty is the best policy. I might occasionally lie to my husband of +20 years (No darling I don't know what happened to your favorite Hawaiian shirt or Yes your Mother is sweet) or the kids (I don't have any cash on me) but *never* to my Dr. My life is far too valuable to fool around with misunderstandings or lies.
I am not after meds. As I said, I have made it this far without any pain meds from a Dr. I can keep that up. I absolutely don't want to be labeled a drug seeker. I need to make sure that I don't say anything stupid that would make them think that. It is sad that folks in pain must be concerned about that (hello choir)... I just want my life back. I want to function in my world again.
I really hope that the wrist guy will be open to taking the case. PT has been very supportive and have kept me from losing any more function than I have. I just have not encountered the same spirit of healing with the Drs. I am ever hopeful that this one is different.
I would never bad mouth any of them to another Dr. I only vent to you guys and my hubby. That's a massive red flag for a health care provider. I do like how you put that..."personality conflict." Sounds much better than anything I have been able to think of. Short and concise. I have been struggling with this all day. My brain just doesn't work as well as it used to.
This whole experience has been an eye opener for me. Not only the physical drain of an injury but having to battle insurance companies and Drs as well. This journey isn't for the weak. Once I get squared away physically...or at least once I am on the way, I will address the errors in my file. I despise having such a cloud looming over my head.
I appreciate your input. It helps to have the benefit of your experience and perspective. Thank you!
Daesin
Understanding is the first step to acceptance, and only with acceptance can there be recovery.
I am not after meds. As I said, I have made it this far without any pain meds from a Dr. I can keep that up. I absolutely don't want to be labeled a drug seeker. I need to make sure that I don't say anything stupid that would make them think that. It is sad that folks in pain must be concerned about that (hello choir)... I just want my life back. I want to function in my world again.
I really hope that the wrist guy will be open to taking the case. PT has been very supportive and have kept me from losing any more function than I have. I just have not encountered the same spirit of healing with the Drs. I am ever hopeful that this one is different.
I would never bad mouth any of them to another Dr. I only vent to you guys and my hubby. That's a massive red flag for a health care provider. I do like how you put that..."personality conflict." Sounds much better than anything I have been able to think of. Short and concise. I have been struggling with this all day. My brain just doesn't work as well as it used to.
This whole experience has been an eye opener for me. Not only the physical drain of an injury but having to battle insurance companies and Drs as well. This journey isn't for the weak. Once I get squared away physically...or at least once I am on the way, I will address the errors in my file. I despise having such a cloud looming over my head.
I appreciate your input. It helps to have the benefit of your experience and perspective. Thank you!
Daesin
Understanding is the first step to acceptance, and only with acceptance can there be recovery.
Hey Daesin.
I got a little mad reading how they treated you.
Don't let somebody get paid to mistreat you.
I've met Surgeons that I didn't care for.I've seen Surgeons that treated me great.I'm just referring to how they talked to me.
I guess I take my Doctors for granted.
I hope you find a Doctor that treats you the way they should.
Rick
53 yr old male.SSDI since 2009.Bulges at L5-S1.......L2-L3.Spinal Stenosis.Arthritis,Degenerative Rt Knee.Scoped x2.Assorted Meds.
I got a little mad reading how they treated you.
Don't let somebody get paid to mistreat you.
I've met Surgeons that I didn't care for.I've seen Surgeons that treated me great.I'm just referring to how they talked to me.
I guess I take my Doctors for granted.
I hope you find a Doctor that treats you the way they should.
Rick
53 yr old male.SSDI since 2009.Bulges at L5-S1.......L2-L3.Spinal Stenosis.Arthritis,Degenerative Rt Knee.Scoped x2.Assorted Meds.
Thanks, M&G, for the link! I did not know we have the RIGHT to have our statements added to our medical records.
I have been trying to get my medical records changed (now I know it should be "amended.") for half a year. It's not done yet. The individual doctors who wrote the erroneous stuff have to be contacted by, in this case, the hospital patient relation dept. Some are on leave, some retired. Makes it difficult.
The last doctor I saw had a helper taking notes. When I got the "report" which they put online, once again there were several errors.
It's a never-ending project, so, everyone, start now to at least make notes, and back up your statements with facts like reports. I keep my reports in folders by body part. I'm starting an "error" folder today.
I have been trying to get my medical records changed (now I know it should be "amended.") for half a year. It's not done yet. The individual doctors who wrote the erroneous stuff have to be contacted by, in this case, the hospital patient relation dept. Some are on leave, some retired. Makes it difficult.
The last doctor I saw had a helper taking notes. When I got the "report" which they put online, once again there were several errors.
It's a never-ending project, so, everyone, start now to at least make notes, and back up your statements with facts like reports. I keep my reports in folders by body part. I'm starting an "error" folder today.
I am really trying to hang in there, I am down to one hand but I am hanging on as tight as I can. Some days are just so much tougher than others. I get so frustrated. Its like fighting a war with limited weapons and your 'allies' are just as likely to stab you in the back as the 'enemies."
It seems like it was a lifetime ago when I felt like a human being.
I keep hoping that the wrist Dr will be the right one. He is the only bit of light in this tunnel. Just a few more days before I know if he is willing to fight this battle with me.
My Dad told us growing up that facing challenges give us character, but even he agrees that I have enough character.
The support and advice this forum provides makes this insanity easier to endure. Thank you all!
It is bittersweet to know that you guys understand.
Daesin
Understanding is the first step to acceptance, and only with acceptance can there be recovery.
It seems like it was a lifetime ago when I felt like a human being.
I keep hoping that the wrist Dr will be the right one. He is the only bit of light in this tunnel. Just a few more days before I know if he is willing to fight this battle with me.
My Dad told us growing up that facing challenges give us character, but even he agrees that I have enough character.
The support and advice this forum provides makes this insanity easier to endure. Thank you all!
It is bittersweet to know that you guys understand.
Daesin
Understanding is the first step to acceptance, and only with acceptance can there be recovery.
I was once fired from my PCP (that I had seen for 20 years) and the entire clinic (which is huge) because I went to a facility seeking treatment for depression. They sent a letter to my PCP stating I was seen by this facility, for "drug addiction treatment" PCP called me in and said they would no longer see me.
I called the depression treatment place and they said since we treat both depression and drug addiction, the letter we send to PCP's just includes both and is the same for every patient. "Sorry..they can call if they want and we'll tell them you just were there for depression."
Well my doctor just says," I'm not comfortable treating a patient with depression severe enough to seek this type of health since I prescribe you XYZ."
Now i cannot go any of the 3 walk in clinics they own(we have 4 in my city), cannot see any of their dr's or specialist, and a big red flag shows up anytime my file is pulled up at hospitals and so forth. I could not get this removed or "amended"
I have also had doctors say I was more interested in pain meds than solving the problem, surgeons who say "despite having great injury to the shoulder patient seems unwilling to accept pain, and chronic instability. Patient often calls for advice when there is none to be given" you should read the notes they write about you! Its insane. LIke if you cry during a visit "patient became very emotional" or "patient seems very agitated" and crazy stuff.
have been labeled as faking seizures(never true NEURO backs me on this) which has kept me from receiving proper care many times, drug seeking, there is no telling what lies are in my medical records and it drives me crazy.
say I go to the ER, at first everyone is all nice and all is well, then they go look me up and its Hell. All because of lies and one or two Dr.'s opinions NOt FACT.
I would do anything in the world to get my records amended, changed and corrected.
sorry you have to deal with this.
and your surgeon...I do not get this god complex some doctors have....ughhh
29 female
Dx's: Depression/anxiety, Non-Epileptic Seizures, repeat Rt. shoulder dislocations, NERVE damage after if IV infiltration with chemical burn in left arm,endo &ovarian cyst. I could go on but will spare you all
Meds: Opana 10mg(waitng on PA), oxycodone 5mg bt, neurontin 100mg, clonzepam 1mg PRN
doTERRA essential oils-Frankinsense, Lavender, Balance,peppermint, Clary sage, and many other
I called the depression treatment place and they said since we treat both depression and drug addiction, the letter we send to PCP's just includes both and is the same for every patient. "Sorry..they can call if they want and we'll tell them you just were there for depression."
Well my doctor just says," I'm not comfortable treating a patient with depression severe enough to seek this type of health since I prescribe you XYZ."
Now i cannot go any of the 3 walk in clinics they own(we have 4 in my city), cannot see any of their dr's or specialist, and a big red flag shows up anytime my file is pulled up at hospitals and so forth. I could not get this removed or "amended"
I have also had doctors say I was more interested in pain meds than solving the problem, surgeons who say "despite having great injury to the shoulder patient seems unwilling to accept pain, and chronic instability. Patient often calls for advice when there is none to be given" you should read the notes they write about you! Its insane. LIke if you cry during a visit "patient became very emotional" or "patient seems very agitated" and crazy stuff.
have been labeled as faking seizures(never true NEURO backs me on this) which has kept me from receiving proper care many times, drug seeking, there is no telling what lies are in my medical records and it drives me crazy.
say I go to the ER, at first everyone is all nice and all is well, then they go look me up and its Hell. All because of lies and one or two Dr.'s opinions NOt FACT.
I would do anything in the world to get my records amended, changed and corrected.
sorry you have to deal with this.
and your surgeon...I do not get this god complex some doctors have....ughhh
29 female
Dx's: Depression/anxiety, Non-Epileptic Seizures, repeat Rt. shoulder dislocations, NERVE damage after if IV infiltration with chemical burn in left arm,endo &ovarian cyst. I could go on but will spare you all
Meds: Opana 10mg(waitng on PA), oxycodone 5mg bt, neurontin 100mg, clonzepam 1mg PRN
doTERRA essential oils-Frankinsense, Lavender, Balance,peppermint, Clary sage, and many other
Sorry it posted too many times
Post Edited (AngMichelle) : 8/9/2014 12:15:33 PM (GMT-6)
AngMichelle, you sought and received treatment for depression, this is not an error that needs to be amended. Have you gotten a copy of your medical records from the facility that treated you for the depression ? That should prove that you were treated for depression and not drug addiction.
Did you mean "it was not an error that needs to be amended" or that it should be? Bc I've never been treated (or needed treatment) for drug addiction and the letter sent to Pcp says depression and drug addiction" they treat both as a facility but I was part of the depression treatment only-but was fired from pcp bc they assumed it was for drug addiction and now drug treatment is part of my records(not easy to explain to my PM doctors on consultations. But mine now is understanding but was one of his 1st questions. His was responsive was "yeah they tend to have a one size fit all letter they send or add to records"
I have found a pcp now that understands just wish it wasn't in there and goes to show what can happen
I have found a pcp now that understands just wish it wasn't in there and goes to show what can happen
Post Edited (AngMichelle) : 8/9/2014 12:28:49 PM (GMT-6)
Being treated for depression will have to stay in your medical records because you sought & received treatment for it. You didn't seek nor were you treated for drug addiction. Your medical records from this facility that the dr made when you saw them should have only you being treated for depression. Unless they believed you also suffered from drug addiction but weren't being honest.