I can't I forget the look of my doctor when I brought up...


Several errors on his notes!

This was my second office visit with this doctor. My primary care doc's office referred me to this knee specialist, so I didn’t know him but his online reviews looked fine. He’s probably an authority because he had a medical scribe (a person whose sole job is to capture the conversation between the doc and the patient and record it) during the both appointments.


What they probably didn’t realize was that I am a patient advocate who deeply believes that every patient would get tremendous benefits by simply keeping an accurate and complete medical record of their own. Naturally, I requested the back office to mail me his notes PRIOR TO leaving the office at the end of my first visit. **Note: This is the best time to do this because you can 1) obtain your record free of charge, and 2) it’s so much easier to correct any mistakes that may be discovered because the note won’t be finalized for a little while.


Actually, it took me another phone call to remind the secretary to mail me his note, but I got it... (Even though I'm used to seeing mistakes on a medical record) I was shocked by the number of mistakes/inaccuracy for something pretty simple, especially because he had someone to take a note for him!


So, at the end of my second visit, I had to inform him about this potentially serious issue. He clearly had no idea this was coming… because he looked kind of stunned when I showed him his own notes with full of my notations of inaccuracy. I said things like “I did not say this, but I said xxx instead.” He was speechless for a little while then checked something on his scribe’s computer... he pointed to me an explanation - my pre-visit questionnaire which was scanned onto the computer. I apparently put down “ice?” (with a question mark - which I admit wasn't a good idea!) to the question what relieves my pain even though I did not tell him “Ice helps with my pain”. So, this is a case in point that patients must be absolutely sure before writing down anything on the piece of paper. You might think your doctor would ask you a question and make sure you really meant what you wrote, but sadly it wasn't the case.


Here is another example:

o My record states: “She gets sharp pain 6/10 in the front of left knee that’s exacerbated with running, stair climbing and standing from a sitting position.”

o What I said: “I have minor discomfort when I run and climb stairs but get sharp pain of 8 or 9/10 when I get up from the floor quickly. (I actually said I can’t pinpoint exact location of the pain but pointed to the whole back side of knee area.)

My doctor's response to this part was it was probably just "a semantic issue" – do they think I meant ‘getting up from a sitting position on the floor’ ...really?


Then the doc was eager to know. "Anything else?" But to be honest, I was a bit tired at this point and gave up addressing all the discrepancies, as those would not be life-threatening issues anyway. As I left, he told me not to worry as the notes weren't finalized yet and he would fix it.


I am certain that this is just a very minor case of medical record errors compared to other patients who have more complex medical conditions and history. And it is VERY SCARY when a medical record has an undetected potentially life-threatening error, and especially when that record gets sent over to a different provider (who might operate on you etc.)...


I really hope patients will pay more attention to their own medical records - your life may depend on it. Always ask for your record at the end of each office visit. When you see any strange thing there, ask your doctor right away. If he or she does not address it, you should call a private patient advocate!

For Inquiry or free initial consultation, please use this Contact Form.
 
443-341-6262
(mainly for urgent cases)

P.O. Box 9344, Baltimore, MD 21228

 ©️ 2020 Patient Advocacy & Beyond, LLC​