Topic: Medical record mistake

I get my name misspelled all the time. It's insane. But as long as my birthday is right, I let it go. Maybe I shouldn't?

Anne

You can contact the medical records department at the hospital and tell them about the error.  Don't be surprised if they cannot correct it based on your phone call.  There are very strict rules regarding what changes they are allowed to make to a medical record, so you may have to go there in person to actually get the change made.

I have a rather unusual first name.  I went to an ER when I was in college, and when they were taking my personal information, they told me there were 2 other women in the hopital that day with the same name!  This is not a large hospital.  I was 17 years old before I met anyone with the same first name as me. Can you imagine the odds of 3 of us with the same first and last name in the hospital on the same  day???  They did tell me one of the other ladies' last name was spelled slightly different. 

During each of my hospital stays (this past year), I had to stop the nursing staff several times from giving me the wrong medication, so I am nervous about what the records show.  I am going to be really pissed if there is incorrect information in there.

Good thing I was there for a bilat mast - they might have taken the wrong one!!!!!  The scariest part of the medication errors was that I was on narcotics and not always "with it".  I CAUGHT the mistake 3 times - how many times did they give me the wrong medication because I didn't notice it was the wrong dose????

The copies of my medical records should be here any day now.  I am already afraid to look at them.

That's a disgrace.  I can see why you are so angry.  That is one of the reason I am so nervous to look at them.  That and I want to know how many times the doc wrote that she was worried about my "emotional health".  Gee, I cried.  I got histerical outside the OR.  I wonder what wonderful things she had to say about that.  Oh yeah, let's not forget the bitch nurse that insisted I sit up and eat something right after I barfed my brains out the morning after sugery, and I refused to do either.  What do you think?  Is there a note that I am a "non-compliant" patient?  There are just so many questions I have that I didn't want to know the answer to when it was happening.  Now I want to know.  I know that I had "post-op" anemia (per my onco notes), but I want to know how much blood I lost, stuff like that.  I can't wait to see what other errors there are besides the whopper that my name is spelled wrong!!

I have a last name that is commonly mispelled.  I have found that the insurance company won't pay out if the office or hospital sends in a bill with my name mispelled, even if everything else is correct.

Checking your records is a VERY good idea, and making corrections as necessary.  Also, once a year you can ask for a list of everyone who has looked at your records from any hospital.  They have to give you this info as part of the privacy act so patients can keep track of who is looking at their records. 

Held,

Please don't take too much offense at the nurses' notes. They are indeed subjective. One person may say "hallucinating" while another may say "disoriented." These are people entering your sphere for just a few moments in a span of time, recording what they saw/what you said or did/etc at that moment. Believe me, as one who has written volumes of notes, it is not personal, and not meant to be an attack.

By documeting that you were tearful and anxious, that is what the nurse saw. How nice it would have been if s/he took a sec to hold your hand and acknowledge what s/he saw. You would get your feelings validated, get some time to vent or cry or whatever, and the nursing note would still say, "Patient appears anxious and tearful."

That said, there is no excuse for inaccurate observations, or documenting the wrong data.

I hope the more pressing issues such as having the name wrong are cleared up.

Anne

I agree that "psychotic" is waaayyy out of line. That's a diagnosis made my a mental health professional, and requires medication as such. However, there are transient psychoses that are not the same as being psychotic, but people who don't knw the difference shouldn't use the word.

If these are just nurses notes, then you do not have a medical diagnosis of psychosis, and nothing sent to the insurance company coding that. You jsut had a totally insensitive and dare I say imcompetent person making a diagnosis that s/he had no business making.

Anne

It is not uncommon to have incorrect information in a patient's chart.

This can happen for a variety of reasons. Different hospitals have different systems, but in my hospital system, a nurse physically writes allergies down on a form. Then the nurses, or other people enter the data into a computer. Sometimes they read the handwriting wrong. Sometimes the nurse or the person who enters in the reaction doesn't enter it in correctly.

Sometimes patient names are identical. Some people have very unusual names. I have seen a last name that was 14 letters long, had 2-3 vowels and 11 consanants. It ended up there were 2 people with identical names. Sometimes orders are written where all the names and numbers are handwritten, so can be misspelled or illegible. Sometimes data is entered on the wrong patient.

If a patient has a psychotic reaction to a medication, I don't assume the patient is psychotic in any way, I just assume they really do have a bad reaction to a medication. Whatever happened, the data may be wrong, and its certainly no reflection on the patient.

When you go again, tell them about the error. I enter in patient allergies into a hospital database all the time, and if the patient denies an allergy that is in the computer, and the patient is 'with it' (not just came out of surgery, for example), then we cancel the allergy in the database.

I have some terrible errors on my records, some absolute totally wrong, and no way can I have them altered.

Years ago, my first DH had about probably 4 years of mental health problems. He ended up being diagnosed with endogenus (sp) depression, had ECT treatment, was admitted to psychiatric hospitals 4 times, and saw umpteen psychiatrists.

The last psychiatrist he saw was a private one, we decided to pay for what we had been told was the best one locally. I went twice with ex DH to see this man, ex DH went  on seeing him for months.

20 -odd years ago I had a car crash, had a bad whiplash, and went to our local hospital to try and get some relief from the pain, during my visits it kept being sort of mentioned I was making it out to be worse than it was, and a lot of it was 'in my mind'

One Dr said, in his conversation to me 'with your history' ....I was taken aback and asked him what he meant. He said with my history of 'MANIC DEPRESSION'  I went beserk at him, no doubt he thought I HAD got manic depression !!....but he insisted that was what MY psychiatrist had written in my notes.

I went to see my GP, and requested a copy of all my records, and there it was....ex DH's psychiatrist had labelled me a manic depressive, I had only seen him twice on visits with exDH, but this man said he had been to see me at home, totaly untrue, when he was supposed to have visited me I had left DH, and was living in another county. He said he had given me drugs, again totaly untrue, and had suggested a spell in a psychiatric ward for me, again absolutely untrue, I had left ex DH at the time he had 'supposedly' seen me.  

I went bananas at my GP but she said she couldn't remove anything at all, she wasn't my GP at the time this had been going on so she didn't know if I was telling her the truth or not, and the psychiatrist in question would not remember me after about 15 years had passed.

By chance in the paper I saw that this psychiatrist was up in court for saying that a woman was  badly depressed when she wasn't. The woman had been going thru a divorce, her ex had sent Dr M. to see her, she was in the bath, came downstairs in her dressing gown, but would not answer the door to the Dr, as she didn't know him, and all he saw was a shadowy figure behind frosted glass. On this alone he labelled her 'depressed'and wrote a report for her ex which was going against her in a divorce case. Dr. M got some sort of reprimand, I can't remember exactly what, I don't know where the article is at this minute, but I kept the cutting, and took it to my GP but she wouldn't do anything, and I knew Dr M would certainly not admit he had made all this up, he would be in more trouble, so I just have had to let it ride.

I do not know what Drs are thinking about me when they see me, I was particularly upset when I was dx'd because I felt, probably wrongly, that all the new Drs I was seeing would think I was a manic depressive it they read back in my records.....so I just had to live with it. Dr M was a particularly emminent dr in this area, he had private practices and spouted at conferences, so how would anyone believe me ??

This will be with me forever now, if I go a bit dotty as I get older, up will come this manic depressive label, and it could alter the way I am treated, maybe ??? As my GP is NOT behind me on this I don't stand much chance of ever being believed.

Isabella. 

Isabella, that is really maddening... didn't mean that to be a pun... but it is terrible, isn't it.  All one's totally justifiable and righteous indignation gets "read" as supporting the false diagnosis!  How awful.

Held, the "psychosis" business is also a drag -- hopefully far less pervasive since it is listed as a drug effect -- albeit a mistake.  I hope you have better luck getting your chart changed.

I noticed about 6 months after my mastectomy that my BS, in her first consult letter to my other doctors after BC diagnosis, said that I reported habitually having 3 alcoholic drinks per DAY!  That upset me!  She and I didn't even discuss it -- I wrote down on the intake form that I drank "socially" and that the MOST I ever have is 3 drinks per WEEK!  I suppose this doesn't make a whole lot of difference, but again I don't like that people will think I'm a heavy drinker, and that I'm "protesting too much" (revealing a "drinking problem" by my strenuous "denial"!!!) by asking to have it corrected!  I'm also concerned that it's bad data, in case my records are "de-identified" for use in some kind of study about the risks of drinking.  Or if it is seen by my insurance company...