We never looked
It's amazing the kind of things that get written in medical records that never actually happened. For those following this blog for the past week, you know that my son was in the hospital following some complications after a tonsillectomy and adenoidectomy. Either myself or my wife was with him at all times. We know for sure that no one ever checked inside his nose or his ears, yet somehow the discharge summary states the nose and ears were clear. No one did any evaluation of his eye movements yet the records indicate this was formally evaluated. These are not huge deals, but still highlight the point that what the records say happened did not necessarily happen. This is important because some people hold the medical records up to be a flawless document that cannot be wrong. As someone who reads through an unbelievable amount of records every month, I can tell you that almost every case has some type of error. Most patients never know because they never get their hospital records. Some of the errors I have read include two different doctors saying the injury involves different sides of the body, inaccurate time sequences, and my favorite: stating something is non-contributory or "WNL."
I recently had a case where all the medical records stated that family medical history was non-contributory. This basically means that the family medical history is not important or relevant to the patient's current state. But what often happens is that health care providers do not ask about the family medical history and just say that it is non-contributory when this is not the case. In the case mentioned above, I had forgotten to ask about family medical history. I wasn't comfortable with relying on the medical records saying the family medical history was non-contributory so I called the patient at home and asked her about this. As it turns out, she had first degree relatives with posttraumatic stress disorder, heart attack, hypertension, diabetes mellitus, and cardiac bypass surgery. Yep, that's non-contributory all right. Unbelievable. It kind of reminds me of the phrase "WNL" when neurologists examine the cranial nerves. This abbreviation is supposed to mean "within normal limits." I am starting to think that it sometimes means 'We never looked."
posted by MedFriendly | 6:49 AM
6 Comments:
"...was non-contributory so I called the patient at home and asked her about this. As it turns out, she had first degree relatives with posttraumatic stress disorder, heart attack, hypertension, diabetes mellitus, and cardiac bypass surgery."
The question is non-contributory to what. It would be wrong to say this faimly history was non-contributory to a patient with an acute MI. However, it would be reasonable to say this family history is non-contributory to a new patient with the diagnosis of breast cancer.
I've got a story about what's in the records. I was sent to a specialist for a tumor in the parathyroid. (Only at that time, we didn't know what was happening). I filled out a symptoms sheet, and when the nurse went over it, she took it upon herself to cross off things I had checked yes to. Those things were heart palpitations, heartburn, fatigue, bone pain. She felt the answers looked too much like psych and not physical. They were in fact signs of a parathyroid tumor. I told the doctor about them anyway, when he asked me questions. She would have masked important information to that doctor! After the surgery, I had no further symptoms.
Isnt it amazing what is contained in medical records and most people dont even know? Chances are, people are not looking over their records nearly often enough. I work with a company called MedeFile International. I had come across your blog while doing some research. In brief, MedeFile is an electronic medical records management service that collects, digitizes, stores, and organizes all of our member's ACTUAL medical records. MedeFile gives you the member, the ability to access your complete medical history 24 hours a day, 7 days a week, from virtually anywhere in the world. In addition, we provide each full MedeFile member with a MedeDrive. The MedeDrive is a portable USB device that works with any Windows based PC. This device simply plugs in to a USB port and instantly auto loads that member's vital emergency information (Allergies, Medications, Medical Alerts, Emergency Contacts, etc). The MedeDrive also has a password protected area that contains all of that member's ACTUAL medical records as well. Our system also provides for the storage of Advanced Directives (living Wills, DNR's, Health Care Proxies) The MedeDrive does NOT require any internet connection to view, and can be updated anytime with no additional charges. What s important, is that MedeFile is a service that does all of the work for you. We have been featured on various news segments with regard to the devastating Hurricanes we have seen in the recent years. MedeFile also qualifies as a medical expense under a Medical Information Plan in IRS Publication 502.
It is very difficuly for people to change errors in their records if they dont know about them. I urge you to visit our website at www.medefile.com for more information. Please feel free to contact me with any questions. Thanks for your blog.
I want so much to believe that everyone does everything right and always for the right reasons. Do I really have to grow up? Ignorance is bliss. I find it unnerving to think these things happen and if not caught errors could be perpetuated.
Good post!
The Doctor-Patient Encounter is a collaborative process. Quality of information recorded in a medical report depends on the source (often the patient) and the doctor. The fact that the patient is the sole source of information during a patient encounter is part of the problem. The patient should not be asked to remember every one of the 20+ medications or the name of that complicated syndrome diagnosed by their neurologist.
DocPatient.com was designed to help patients manage their medical information online in collaboration with their doctors. Doctors can participate at a basic level for free. The information connects directly to the doctors site so there is no problem transferring the medical information directly into the doctor's chart and vice versa. All information is kept secure. The patient's copies of medical records belong to the patient. The Doctor's medical records belong to the doctor. Transfer of information from one to the other is at the discretion of the information owner - all of this is HIPAA compliant.
Patients can enter "medications, allergies, past medical history, past surgical history" and most other information to help provide their doctors with the latest information. When doctors "accept" this information into their digital medical record they can update the information as needed. This updated information is then immediately visible to the patient through the patient's secure website.
Doctor's can transfer medical documents such as lab reports, MRI reports and other information directly into a patient's clinical vault without a fee. Doctations allows the doctor to send secure message correspondence to the patient reminding the patient about the doctor's assessment and plan. By the way, doctors can do all of this for $35 per month or $399.99 per year which includes state-of-the-art scheduling, up-to-day pharmacy information, a national white pages of pharmacies, doctors, hospitals and insurance companies, and a lot more. All through a standard web browser.
If their doctor is using Doctations, then the patient can message their doctor and send internet requests for medication renewals.
Patients can even FAX their medical information into their "clinical vault" or they can scan and upload files into the "clinical vault". While all of the above functions are available without charge, the cost for storage of medical information online is $9.99 per year for an individual account or 29.99 per year for a family of six.
DocPatient.com is available right now. Patients can store their information online by faxing or uploading right now. Anyone interested can call 1-877-DOC-PATI ent or email Doctations@Doctations.com. - Lou Cornachia, M.D.
I dont know about DocPatient, but MedeFile is a croc, even a scam. I spent over $500 on this "service" only to find that all they did was get faxed copies of records that they stored electronically. They were not even complete records. There were gaps, even from the same doctor, and repeated pleas for help were unanswered. Then, suddenly and without warning, they vanished. The service just stopped. They placed an ominous "warning" message on their site stating that the website was undergoing maintenance. A quick look at their financials shows they're broke and the stock price is less than $0.01. Now, who knows where my precious medical records went. I know my money was spent for nothing!
BEWARE! MedeFile should not be trusted
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