Jump to content

Medical Records-How do you revise?


Poohbear
 Share

Recommended Posts

Hi Everyone!!

I need to have some corrections made to my medical records. Has anyone else had to deal with this?

I am wondering if there is an "official" way I am supposed to request the corrections be made and how I should go about doing this.

Do I have any say in this or is it always the right of the Dr to write what they want?

My dilema is that in some cases when I consulted with this Dr. he didn't thoroughly read the notes I brought with me from other Dr.'s so his notes make some comments that are just wrong. For those statements, I can copy the other Dr's notes and/or have the initial Dr explain his statements in writing to support me.

In other cases, the Dr took something I said and misinterpreted or only wrote half of what I said; thus the comments that were made are misleading and only half truth. For example, I said something similar to "When thinking about this visit the past couple of days I've been weepy because it reminds me of the things I've lost"

And the Dr wrote something similar to, "Patient says she cried the past two days and is depressed". That's not what I said and that's not true! I wasn't really depressed, I was GRIEVING...makes a difference. These inaccurate comments could impact whether I can keep my LTD benefits or not so this is a big deal to me.

This Dr also told me that I would need to find a job I could do from home. Yet, in his report he makes no mention of this. Is it inappropriate for me to request, even though I know they don't like to get involved in disability paperwork, that he include this in his note?

As always, thanks for your help!!

Link to comment
Share on other sites

I am curious about this too. I had a wrong diagnosis code on my records for years and could not get insurance to cover female issues cue to the diagnosis code. I argued and did everything I could but I was stuck with it. Dr told me he couldn't change it - I never believed him.

Link to comment
Share on other sites

As for getting your medical record changed, it will have to be the doctor that made the mistake or was doing the dictating. A transcriptionist can't change what a doctor said based on what a patient requests.

And I've learned to be careful what I say to doctors as their own warped views and bias can make your life a worse living **** then it already is. Talk to the ones that you trust and feel the new ones out.

good luck

Link to comment
Share on other sites

Getting what is already there changed is VERY difficult...generally it can only come from the person who originally messed it up in the first place, which half the time is the problem! An addendum, however, from that person, another nurse or doctor or medical professional from the same institution/office, or even yourself can be added fairly easily. This doesn't get RID of what's already there but at least then the "whole story" can be there. I believe that anything you present to be included in your medical records must, by law, be included. Of course most aren't going to look the same at info from a doctor & info from the patient him/herself, but it's better than nothing. Another way to give something you write more "substance" is to have it signed off on by a doc. SUch that if you have a good or at least decent doc now who agrees with what you're writing they could sign the bottom perhaps. I haven't done this in terms of corrections but know that when I've taken symptom logs, etc. to my doc she often just asks to keep it, signs & dates it, & adds it to my chart. I really don't know if you can make something "disappear" though...recently my primary doctor told me know (and I love her & her staff...it wasn't anything of theirs that was the problem). There was actually an error in medication & discharge planning in my notes from Vanderbilt. Vanderbilt requested that the draft (that was in error & hadn't meant to be sent in the first place) be trashed and replaced with the new/final copy. My doc's office said they couldn't do so by law. They made a note on the draft/erred copy & attached the revised/final/correct copy, but the initial goof-up is still there. I haven't looked into it further but that's the bit of knowledge & familiarity I do have with the issue. I know that there's lots in my records that would be better not there, but ultimately anyone who knows whats what and is working with a patient in the here & now can differentiate. I have everything from off-the-wall psych allegations to hospital discharges stating I am a 55 yr old woman (I'm 25) to wrong diagnosis based on my meds (b/c of taking them for different reasons). Depending on the setting though I just don't forward things that are entirely off-base, for instance when I sent my records to Vandy I didn't send them wacky records that have since been debunked time & time again...they had asked for relevant records so I didn't feel odd doing this.

Good luck!

:-)melissa

Link to comment
Share on other sites

In the past I've sent an addendum to clarify--it's nearly impossible to get a medical professional to fix anything on a report unless it's glaringly inaccurate--like stating you're a male instead of a female. I've only had one professional who actually changed her report based on my letter as an addendum. Simply request within the opening sentence of your letter that you wish for it to be added to your permanent medical record.

Nina

Link to comment
Share on other sites

Thanks! Once again, I'm finding myself angry because out of one Dr's carelessness it has started a "chain reaction" and I feel like I'm fighting an uphill battle and it could cause me to lose a little more than half of my monthly income. I'm so afraid of ending up homeless!!!

I get so tired of fighting for benefits that are supposed to be rightfully mine. I've worked many years and was an excellent employee and all my employer is concerned about is their bottom dollar. They are looking for any way possible to discontinue my LTD benefits and I can't survive on my SS check alone.

Link to comment
Share on other sites

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.

Guest
Reply to this topic...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.

 Share

×
×
  • Create New...