Do not lie in the medical record!

Last week, I spent 8 hours in the ER and 2 days in the VA hospital. Today, I looked at the medical record for that time. During that entire time, no one touched me except to do my vital signs, draw blood, and do an EKG. But the ER doctor and the admitting doctor BOTH recorded FULL, totally normal, physical exams for me.

DO NOT FUCKING LIE IN THE MEDICAL RECORD. I AM SERIOUSLY PISSED! My physical exam is NOT normal. Tomorrow, I will be visiting the VA to file a complaint.

Well, they thought they thaw a pudytat

This is U.S. healthcare. If you want to convince them that there’s something seriously wrong with you, thank them politely for providing excellent medical care at a reasonable price.

What was your admitting diagnosis? I have trouble believing an ER doctor got you admitted without examining you. Sometimes a patient can be admitted with a partial exam, though it isn’t supposed to happen. An example would be a trauma confined to an extremity. Chief Complaint: “I have a fucking arrow in my leg”.

Sometimes I think that people in the future will look back on present-day U.S. health care the way we look back on health care from the days when doctors didn’t wash their hands between patients and thought that bleeding was the remedy for everything.

It doesn’t fucking matter what my admitting diagnosis was! You don’t document in the medical record that you did something when YOU DIDN’T DO IT!! THAT IS FRAUD!

Now, the ER doctor did talk to me and documented what we talked about. I was a bit surprised that she did not examine me after I mentioned some other physical symptoms that should have prompted an exam. But the admitting doctor also documented a physical exam that THEY DID NOT DO!

I was admitted (voluntarily) for major depression, suicidal intent with plan.

That would not require a full physical, so I wasn’t particularly surprised when she did not examine me.

But I told her about shortness of breath, weakness, and tachycardia necessitating sitting down 4 times while mowing the lawn 2 days prior (I mowed the lawn, without stopping, a month ago, but she did not ask about that) I told her about my patent foramen ovale (congential heart opening that did not close)

I told her about my abdominal pain the day before admission that I felt was my abdominal hernia expanding. That should have prompted an exam. (I have had a strangulated intestinal hernia that required surgery 10 years ago)

But the bottom line is: She should have documented that she did not do a physical exam. She documented a physical exam she did not perform. SHE LIED. That is fraud.

(I have been a family practice doctor for 38 years, recently retired)

I get an annual physical. They check my vital signs, draw blood, and (sometimes) do an EKG. Other than that, it’s just a bunch of questions. What else were you expecting?

Yup. My annual physical is a fifteen minute affair inch of questions, mostly from nurse-type person, check of vitals, order for a blood draw, and out the door.

A d i ha have never seen a medical record. Where do you get one of those?

Based on your first post I was about to ask if you were sure that one of the people who did vitals didn’t listen to your lungs at the same time and might that person have been a doctor and not a nurse. See I’ve been on the other side of this where the patient says they never saw a doctor/were never examined when in fact they saw the intern, the senior resident and the attending. The real problem was that they never saw a male doctor. But what you’re describing is inexcusable.

I don’t know the specific system at the OP’s VA hospital but as an ER doc I can tell you that when someone comes in with a psychiatric complaint my basic role is to “medically clear” the patient for psych. Meaning I need to determine that there is not a physical problem that is the source of their psychiatric symptoms and that they do not have a coexisting medical problem that would necessitate admission to a medical service because they can’t be safely cared for on the psych floor. So based on the OP’s symptoms of SOB and decreased exercise tolerance and older age look at his feet/ankles and listen to his lungs for signs of fluid overload that might indicate new CHF and listen to his heart for new murmur that would indicate a new valve problem like aortic stenosis. Based on the history of strangulated hernia and abd pain yesterday at least press on his abdomen to make sure he’s not tender and that any palpable hernia is easily reducible.

All that is for patient safety. It completely leaves out the fact that documenting a physical exam that you did not perform is in fact fraud because medical billing is based on the complexity of your medical decision making which includes how extensive a physical exam did you perform.

Falsification of medical records is grounds for license revocation! You have every right to be angry.

The o.p. is dealing with the Veterans Health Administration (the health care section of Veterans Affairs) which is widely known for overwork, incompetence, and corruption including denying mental trauma claims of veterans who did not serve in dorect combat positions (even if they were exposed to actual combat) and falsifying scheduling data to deny that the agency failed to provide health care and mental health services to veterans in imminent risk who subsequently died from their conditions. What he describes is beyond the nominal carelessness of profit-based healthcare and is an example of gross negligence. Even psych intakes should require the kind of exam pendgwen decribes just to assure that there aren’t physical symptoms of an underlying condition that exacerbates the patient condition or could interfere with treatment.

Stranger

It’s clear that I should’ve checked my younger, (so far) healthier privilege on what constitutes a physical exam. Apologies.

“Honest, I only drink a couple of beers a night.” :dubious:

Sometimes I doubt that physical exams actually document all the minutiae that appears in the medical record, including complete neurological exams for patients without neurology-related complaints. But if two separate docs actually did nothing but claimed they performed physical exams, that’s really bad - even for the V.A.

It is a program called MyHealtheVet- a website where you can request prescription refills, make/change appointments, send messages to your doctors, and read/download copies of your lab results, other tests, and see your medical visits/hospitalizations. No one told me the results of my lab work, so i wanted to check that, and I wanted to read how they viewed my problem. A very handy program for Veterans-run by the VA

I had many people over the years tell me that they had never had a physical exam as thorough as the one I did on all of my patients.

(When I was doing Locum tenens, I saw a 55 year old man come into the office with the complaint of a kidney stone. He had blood in his urine, and classic back pain, and a recent history of kidney stones. I noticed that the nurse had put a ? in the space for his blood pressure. “Hmm, why did she do that? I’ll check it” Right arm was 200/120, Left arm was 180/110!! I had him lie down on the exam table and listened and palpated his abdomen. He had a 7 centimeter diameter pulsing aortic aneurysm in his belly! I called the hospital and they sent a helicopter to pick him up. When I spoke to the wife the next day, she said “I’m sure glad you were in the office yesterday. I don’t think his regular doctor would have caught it”

Old saying: Good, Fast, Thorough. you get 2 of the 3 options,rarely all three. I was good and thorough. I knew one doctor in 38 years that was all three-he was a wonder to behold!

As an ER doc, I’ll tell you that I also told her about my recent self-treated bout of superficial thrombophlebitis in my right leg where I had had a DVT and subsequent pulmonary emboli in the past, and the fact that my last d-dimer test was over 1200 (normal less than 250) in 2017. But I did not think my shortness of breath was due to a PE.
The psychiatrist put quotation marks around my comment of a “massive PE” in my past medical history. Here’s the comment from the radiologist about my CT with contrast at the time: “There is pulmonary embolus in the main right and left pulmonary arteries. There is also pulmonary embolus extending into the right lower lobe, as well as the right middle lobe branches. There is pulmonary embolus extending to the left upper lobe anterior segment branch”

Yeah, I try to wait to get sick until I’m overseas.

You know, even though our kitty’s admission was for psychiatric treatment, I think he’d rather avoid the “delusional” parts of the manual.