Yeah, they were definitely fired. My sister worked in the same system (different hospital), and, yeah, looking up a patient’s record that you did not have very specific medical reasons to do was an automatic boot.
In the Police Industry, cops are the brothers in blue who not only don’t police themselves, but they stand up for each other and always claim there is nothing wrong going on.
In the Health Industry, the doctors are the brothers in white, and they do stuff like make comments like you just did, which is basically the same as the cops. Correction *the “majority of the cops”
Once on line looking at my medical records I found an email that from a PA that was filling in for my specialist doctors at one of my appointments,the email was sent to my primary doctor, and stated things that were not only negative about me but it also stated things that were incorrect and didn’t happen. It was clearly obviously that I wasn’t suppose to be reading the email, and after I complained about it, it then disappeared from my on line records (available to me).
ALSO, when I first started using the on line records, it was to look up my lab results. Well, it use to show WHEN and WHO looked at my lab results with name, date and time and how long they look at it. I could see how long it took for my doctors office to look at my results or to see if they ever looked at my results.
But after a few years, all it ONLY showed was my name and only when I looked at the results.
That would tell me that they are keeping part of it secret to cover their own ass, just like cops try to hide body camera footage.
The police Industry are also just like the Health industry because they both treat poor people differently then rich people. They both believe poor people are trash and can’t afford attorneys to sue them and Rich people lives are more valuable and they can afford to sue you and deserve better treatment.
Your experiences are your experiences. I can only say what I have seen. I’ve worked mainly ER. When you write on the chart, you’re making three copies. Altering notes is a huge no-no but in the ER it would be almost impossible to do.
I’ve seen very few patients I thought were unpleasant. Those patients still got my highest level of care and advice. I would never chart anything that might imply otherwise - and would always stick to the facts. Do most other doctors do this? As I said, I can count on one hand the times I’ve seen a negative personal opinion expressed in writing on a medical chart.
@Dr_Paprika Your experience reflects mine. Altering charts = bad bad bad, fines, medical board discipline, loss of privileges, loss of job. I work in a prison and I work hard to make sure I and my staff can provide the patient’s legit medical needs, no matter their attitude.
At your ER, how about when doctors look at patients records? Is it recorded who, what doctor or nurse looked at the records and when?
And is that information available to the patients there, or are they secret?
Cause in my experience, I use to be able to see that, and now I can’t. They changed it, they hide it, they made it secret. It’s one example of many where they have secret stuff.
Agreed. With electronic records, it’s pretty much impossible to alter a record. Labs, x-ray results, etc. are not generated by the treating physician. Electronic records, at least the ones I’ve used, also do not allow for altering the record. Addendums can be added, but the original record cannot be altered or deleted.
Those things are kept track of, but not by the physicians themselves. I have no way of knowing which other providers looked at what record, on what date or time, or for how long, because keeping track of those things isn’t my job. There are people who do keep track of such things, and they aren’t there to cover up for the medical providers.
You are soo dedicated to your brothers in white, just like cops stand up for their dirty brothers in blue.
They didn’t police themselves and now they have to sleep in the bed they made.
One day the Health Industry will do the same thing the police are doing to themselves and then the Progressives will take over the hospitals and make health care for all and it will completely change how everything is run.
Well, the point was, someone said “NO SUCH THING OF SECRET NOTES”.
I know I once could see what doctors looks at my lab results and it was changed so now I can’t.
Now it is secret. I know “they” still can see it, but they are keeping it secret from me, like other secret notes in my files. But they still let me see when “I” looked at my files, just nobody else. Why would I want to know when “I” looked at them? Wouldn’t it be better for my to know when anyone else looked at them?
I’m not a Brother in White. I’m not working in health care. I know a lot of doctors. They aren’t dedicated to covering up each others mistakes: they are pissed off and sometimes vindictive when they have to do extra work to correct somebody else’s mistakes, or even when they have to work with people who make mistakes.
At worst, they are supercilious with an enhanced sense of their own superiority over people who make mistakes.
At best, they understand that errors are human.
On average, they understand that Doctors who make errors are Doctors who they do not wish to work with and who they do not wish to share facilities with.
If you have been in contact with multiple doctors, who have not agreed with you, it suggests that you’re the soldier walking out of step – not the rest of the squad.
There’s a bit of a meme in British comedy that doctors use various acronyms to indicate in the notes that a patient is particularly annoying or stupid or whatever.
Perhaps a doctor here can clear this up (and sorry if this is a hijack), but I think it’s bogus. Because if even half of the anecdotes are true, then doctors need to memorize a bewildering array of very specific acronyms just for the purpose of a secret joke.
I am responsible for my father, resident in a “memory care” facility. He’s not aggressive, to say the least. But if he did become aggressive, of course there’d be a record made of that.
But here’s what I know, for an absolute, incontrovertible fact:
If he falls, and especially if he falls while being cared for, or moved, or put into bed, or helped out of bed, by a staffer, there will NOT be a record of that.
He who keeps the records creates the history. It’s absolutely a position of power, and it’s hard to refute.
I would make a report of that to the state agency that oversees that nursing facility. At all the facilities I work at, falls are very carefully documented. Whether the fall was witnessed or not, the location, the time, any injuries sustained, etc. The nurse will write a note in the nursing section of the chart, notify the doctor, and after assessing the patient the doctor will write a note as well. In addition aggregate data is collected on a monthly basis and reported to CMS, along with many other metrics such as rates of infections, usage of antipsychotic medications, number of patients that develop wounds, and so on. If there is a trend such as falls being located on a particular unit or during a particular shift, a performance improvement plan has to be formulated to investigate and address the problem. State surveyors will show up and investigate any report of a fall that isn’t documented, and they aren’t there to just help cover things up for the facilities.
ETA. If state shows up and they find evidence of falls that aren’t being documented or even when they are documented but not in a timely manner (meaning the physician not notified within a few hours, and I have seen that happen), people will almost certainly lose their jobs, and not just the CNA or shift nurse. I’ve seen administrators fired over that sort of thing. It’s not the sort of thing that goes on routinely.
“Will not need referral to proctologist. Patient is a Perfect Asshole.”
I saw my doctor’s notes where she described me as agreeable and having a good sense of humor. I assume the purpose of such description is to note any mood changes at later days. If I’m suddenly irritable or sullen it might indicate some problems.
Acronyms were used in familiar books like House of God but I’ve never seen them in practice and assume they are apocryphal or archaic.
Every doctor makes occasional mistakes and functional departments use them as an educational opportunity. Doctors do not like “cleaning up” after repeated big mistakes and Melbourne states it well.
ER doctors often rely heavily on paramedics and nurses who often know relevant details which may be discussed. Again, having seen thousands and thousands of paramedic, nursing and health care provider notes - seeing written unflattering character judgements is extremely uncommon. In cases where there may be an issue, it is almost always stated in factual terms avoiding overpersonalization.
As well as opening up oneself to a ton of legal liability.
My mom was involved in only one malpractice suit in her entire nursing career, as a witness. It was discovered that he doctor had gone back and altered the chart and game over.
Sort of like a warrant canary – not saying something that is normally being said is all that’s needed to convey the message, in a way that’s a lot harder to use against you.