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Watch your medical records - rock bottom


Posted: Jan 14, 2015

Since Septemer 2014, every visit with every provider has gone like this.

1) The medical assistant types into my record.

2) The provider types into my record.

At the end of my visit, they hand me the summary of my visit that day. It goes like this

1) The medications are mostly right although some are wrong and way wrong.

2) My age is off by 10 years at one facility and they 'cannot correct it.'

3) My height and weight are off a whole lot at another facility and they 'cannot correct it.' (I'm 4 feet 10-3/4 inches, 114 pounds, BMI 23; they put 5 feet 10-3/4 inches, weight 114 pounds, BMI 16 which is anorexic).

4) One provider put I have paralytic ileus (I have gastroparesis, and they are NOT the same disease).

What is happening is that only so many drugs and diseases are coded into the template, the rest need to be manually entered. I think they're just clicking something 'close enough' and hitting enter.

I didn't put up too much of a fuss, I'm still competent enough to argue the point. But, when enough clinics/hospitals get sued for CPSEs that actually do kill the patient, we'll be back in demand.

Never ever thought it was a good idea to have providers doing their own reports. Drafting my letter to you know who now.

Best wishes,

 

 

 

I have advised my family...... - ....to always check....

[ In Reply To ..]
....their medical records and told them if they think anything is not right they can talk to me about it.

Agree... - Former MT

[ In Reply To ..]
...providers should not do their own reports, but (sadly) don't think this will lead to our ever being back in demand.

Though it would be great to be wrong.

You are so right sm - Yep

[ In Reply To ..]
I have a physical about once a year and since the docs have been entering their own information, I've found a few serious errors about weight and blood pressure, also PMH. I didn't check the record until I got home and haven't called the office regarding the errors. I'll do that during my next visit. Thank God I don't have anything seriously wrong with me, otherwise I'd be in big trouble. Wait until they start seeing increasing malpractice issues that they have to fight, then they'll understand why they need editors, transcriptionists and quality control people. They won't realize it until it hits the administrations in their pocketbooks.

I've been seeing the same doctor for 15 years, - yet at every visit I still have to -

[ In Reply To ..]
remind her that I had a hysterectomy in 1984, when she says I need a Pap smear.

They are wrong if they are telling you it cannot be - corrected. You need to put the request

[ In Reply To ..]
and reason in writing and they are obliged to make the change or explain why they are unwilling to do so. In your case, it should be a simple oops, fix.


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