““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.””"
Yes your right. Just like when a black driver is pulled over and searched multiple times over his life time, it suggests that blacks are out of step.
Police and doctors have soo much power.
I don’t know much about “Alter charts” but I know they have “secret notes” and other secret information.
I don’t know if this is a direct comparison to what you’re saying. But I have a relative who is becoming a nurse (just graduated, and about to take the RN exams) and she has done shifts in hospitals (and a pretty decently rated one). According to her, it’s routine for nurses to just make up stuff on their reports. Specifically, if they’re supposed to be monitoring such-and-such or performing such-and-such procedure at a certain time and then documenting having done so in the patient’s charts, they frequently just fill it all in in advance. Which isn’t to say they never do the actual stuff, but that the reports ostensibly documenting their having done so are completely bogus.
I did make a report, to the New York State Department of Health, Division of Nursing Home and ICF/IID Surveillance. Nothing happened.
Look, you describe very well what should be the procedure in care facilities.
Here’s what happened:
Before he moved to his current residence, my father spent a long period of time in a rehabilitative medicine facility for older people. And, by and large, they did a great job. They got him walking (with a walker) again, which he hadn’t been able to do for a while.
But (there’s always a but). –
I came in to visit him one day. Important detail – some patients had private care nurses and/or aides, i.e., people employed by the patient to provide care over and above what the facility provided. I don’t know if this is common where you live, but it’s very common here. Every nursing home, every memory care facility, that I’ve seen (and I’ve seen quite a few) permits this.
Anyway, a private care nurse came to me and said that she thought I should know that they found my father on the bathroom floor the night before. Apparently he’d fallen in the bathroom and couldn’t get up, and was there on the floor for a few hours before anyone found him. And the nurse told me that this wasn’t the first time.
I immediately, of course, asked to speak to the floor supervisor. I think she was an NP. She said that’s terrible, and if anything happened, it would be in the log. So she got out the log for that night. Unsurprisingly, there was nothing. So as far as the facility was concerned, nothing happened.
After my father had moved from that facility to his current residence (because I feared that the facility would retaliate), I made the complaint. It was determined to be unfounded, because the log “proved” that no such thing had happened.
Does this really surprise you?
In his current, very expensive, residence, the response from the director to any complaint, or even mild implication that they could be doing something better, is “we’ll be happy to help you find a more suitable residence for your father.”
So that’s the reality.
You “know” this how?
Aside from maybe blowing off steam in a personal note (“Dear Diary: today I dealt with a Total Asshole”) there is no magical Secret Medical Record that only the anointed can access.
As I mentioned in a previous post, electronic medical records (which dominate today) provide very specific information on who documented what and when. Attorneys routinely demand such records and experts can tell exactly when someone checked a lab value or imaging result, or if a record was altered.
““Metadata” is the unseen, embedded “data about data” that tracks every keystroke to a computer. Because of metadata, delete does not mean “good-bye” and alterations and after-the-fact entries are 100% clear if someone wants to challenge the record. When the date, time, entry or source of entry is in dispute, metadata gives the “who, what, when & where” for everything. In the context of a medical malpractice case, metadata will play a role if the timing of entries is relevant. It can reveal significant gaps in time if, for example, an entry for 10:00 am was electronically recorded at 2:30 pm, which could be at the end of a hospital nurse’s shift. Using this example, nurses can be asked why there is a four-and-a-half hour time gap between the noted and actual entries. They can also be asked whether the entry is completely accurate as to what occurred or was observed at 10:00 am, or if the information recorded at 2:30 pm is less than accurate, based on the patient’s change of condition during the four-and-a half hour window. Most significantly, metadata will reveal with clarity if the record has been altered in any way once there is a negative patient outcome. More often than you care to know, health care providers are tempted to change a record to their benefit if they find out that they are being sued, or that a lawyer has requested a copy of the chart. With electronic medical records, there is no way to hide changes to the record, whether innocent or not.”
Conceivably a doc could get in trouble (or be vindicated) by a simple text message to a patient or colleague.
I know what metadata is (I do this stuff for a living). I also know how to make it disappear.
Some of that is surprising, some not. Was this before COVID-19? If so, the lack of any response from the state is surprising. I’m from Texas, so I’m not familiar with the state department in New York, but here whenever a report is made to state, the state investigator has always shown up to the facility. I can’t recall a single incident where they haven’t. There could very well be a nurse / some nurses who don’t document something that happened, but if they are doing that routinely, they will almost certainly be found out due to the nature of falls in the elderly. Sure, sometimes there won’t be an injury, or maybe it’ll only be something minor such as a small skin tear. But eventually someone will fall and break their hip, or develop an intracranial hemorrhage, or some other severe complication, and that isn’t going to go unnoticed. Eventually they will get discovered due to the large number of people involved in the care of the patients. There’s going to be at least six nurses and six CNAs (morning, afternoon, and night shifts and a separate crew for the weekend), therapy staff, the doctors, and so on who all lay eyes on the patients. It might not happen right away, but eventually a nurse not reporting falls will get discovered.
As far as your experience with the more expensive residence, unfortunately that doesn’t surprise me. There are some administrators who lack social skills, are frustrated with the job, overworked, etc. It doesn’t excuse that sort of response to a family member bringing up a concern regarding the care of their family member, but I do understand why something like that might happen.
I’m not saying that nursing homes are all excellent. None of them are perfect, some are worse than others, and on some rare occasions they reach the point they get shut down by state. But routinely covering up falls isn’t something I’ve seen, and would be extremely difficult to get away with under most circumstances.
Before. And there wasn’t a “lack of response” from the state. They responded. The logs were examined. They “proved” that there was no incident.
The New York nursing home industry, and the state regulation thereof, are notoriously corrupt. It’s a shitty business, dominated by sleazebags who make the Kushner family look like Mother Theresa.
She’s not overworked. This is a small, incredibly expensive facility, not one of the Medicare/Medicaid mills in New York. She’s just someone who really, really loves being the biggest fish in a small pond. This is very, very important to her.
The number of physicians capable of making metadata “disappear” from a medical record is somewhere between infinitesimally small and nonexistent. One would have to conjure up elaborate conspiracies involving IT staff.
Never heard of such a thing happening.
In our office at least, we keep a hybrid system. Notes are taken on paper and stored in paper charts, to be entered in at a later convenience. ‘metadata’ about when a note is scanned in is not as definitive as it might be for an all-electronic practice.
The doctor’s visit note, however, is all electronic. Changes are logged the moment the note is electronically ‘signed-off’ on, and occasionally drafts are saved, too. The doctor can make revisions but old revisions are stored in the record. It is impossible for us to fudge the record because the data is stored with our vendor’s company off-site and out of state. Printouts are stored in the paper chart, but for office notes there is always an electronic record.
Our electronic health record does not have a respond-to-subpoena function, so when we get one it is literally me going into the chart and copying everything I think is relevant to the request. There are actually many parts of the electronic record that are nearly impossible to export - as manager I will end up copying and pasting text to Word and printing it out with my signature and pain of perjury as a guarantee of accuracy. If a lawyer needs more than what I’ve sent they will contact me and I try to procure whatever they are looking for.
~Max
Attorneys routinely demand such records?
Why would attorneys have to “routinely” DEMAND such records? Were they try to be kept SECRET?
If they weren’t secret, you wouldn’t need to pay an attorney to DEMAND them.
Plus if your poor and can’t afford an attorney, they information will remain secret.
And the doctors know by the type of insurance you have or don’t have that you are poor and the secret notes will remain SECRET.
I was speaking of malpractice litigation, either filed or contemplated.
The point (yet again) is that 1) TOP SECRUT/“dark” medical records are conspiracy fiction, and 2) going back after the fact to change/alter medical records is bound to be discovered and count heavily against a doc or nurse, even if they are making a change to reflect actual events not initially logged.
By default, we are required to keep records secret from everyone who isn’t the patient. While the patient can request we release records to an attorney, and we will comply, the attorney sends a demand (subpoena duces tecum, latin for “under threat of penalty, you will bring it”) so that we can be held in contempt of court if we don’t comply.
~Max
Well we must be speaking of different things then, cause I was going back to the FIRST comment that started this thread, I’m assuming it was suppose to be what this thread was all about, which is doctors making nasty notes about the patients in the patients files that we normally don’t see.
The facts are this is true. There is information in our files that are wrongfully kept secret, I’ve given a few different examples of this. Just because you say rich people can hire an attorney and get the information, doesn’t mean its not completely kept secret from poor people that the doctors know can’t afford an attorney therefore KNOW it will be secret forever from the get go.
If I asked for a copy of my medical records, they would give me my records but they might charge a fee that poor people wouldn’t be willing to spent to get them.
All these medical records they give you will not have a lot of secret information, like the doctors private notes or a doctors note to a different doctor, nor will it have the information like when doctors looked at your lab results or if they ever looked at them. They have this information, they keep it, but they will not give it to you with out hiring an attorney to demand it. If you have no money for an attorney your out of luck. And the doctors knew this from the beginning, that’s why you might have more nasty secret notes then others. It’s obvious that the person’s doctor who started this thread made a mistake and allowed one of these secret notes be seen by the patient. Just like I had a PA filling in for my DR who did the same thing.
You doctors are just like cops. You need to stop and admit these things occur and correct them.
Absolutely. We put little marks on patient charts if, for example, they are persistent in not wearing a mask (which we require). That serves as a heads up for staff interacting with the patient. It can change how staff interacts with the patient, for example the receptionist might peep out into the lobby more often to make sure the mask remains on. If a patient asks for us to release records, that little note will probably not be included.
If we are the defendants in a malpractice lawsuit, that’s different. But for most purposes, our internal notes are completely irrelevant to the clinical record.
~Max
Of course. It’s probably about the same as the number of physicians who respond to document demands themselves, and actually pull and produce produce documents.
I have seen about a million document demands. And responsive document productions. And I’ve seen quite a few times documents produced in electronic form without metadata, even though the metadata was part of the document demand.
Just say “YES, we have secret notes, that may not be always correct or nice and it might make the patient look bad to other doctors, while us doctor remain looking great”.
And their is nowhere in the patient’s file where the patient can add notes about the doctors he or she has seen and any complaints about them.
You mentioned a secret note may be something about the patient not wearing a mask, well this thread was started because one doctor’s notes said “The patient is a very pleasant gentleman". Is that proper? I personally can be an asshole, is that what is in my secret notes and would that be proper?
We don’t share our internal notes with other doctor offices, it stays with us.
When a doctor writes “patient is a very pleasant gentlemen” that is on the official clinical record. We give that record to patients and other doctors upon request. As mentioned above that sentence (not word for word) is actually part of our template, so it gets put in every note automatically. The doctor will remove the sentence if he thinks it doesn’t apply. The absence of the sentence proves that the doctor willfully removed it, but this is not true of all doctor’s notes, only our practice which automatically puts the sentence in.
This is not true. A patient who maintains their own medical file is free to put in whatever notes or criticisms he or she pleases. Many times a new patient has come and asked me to copy their personal medical file for our records, and the patient has written down unsavory opinions on services provided by a previous doctor.
Furthermore, a clinically relevant letter or other communication from the patient to our doctor is always added to our file on said patient. While a nastygram (a nasty letter/fax/email) that is clinically irrelevant can technically be thrown out, we aren’t allowed to throw away clinically relevant communications and so in practice we keep them.
Some people are assholes, or crazy. Doctors are people too, and of course every doctor will think of at least some patients as assholes or crazy people. Doctors and staff are also professionals, so it is our ethical duty to put that aside when possible. Very very rarely will we fire a patient for their attitude - it would have to be such a problem that it is impossible for us to provide treatment. For example, if the patient is sexually harassing the nurses and won’t quit it, we will fire the patient. The medical record will reflect that we fired the patient because they didn’t stop harassing our nurses. Other doctors who request records from us will see that we fired the patient for sexual harassment. It’s no secret to anyone who has permission to see that patient’s records.
But the internal notes I spoke of, those are not released to other doctors or generally to any outside party. They are only to give notice to our own staff members who interact with the patient. If we mark the patient as noncompliant with mask policy, or someone who is noncompliant with pet policy, or someone who has a service animal, or someone with a disability (blind, deaf), or someone who needs an interpreter, or someone who uses public transit, or as someone who has a high deductible and needs to know the cost before services are rendered, that is only to prepare staff for patient interaction.
Some of these will make it into the doctor’s clinical notes independently of our internal notes, for example, a history of medication noncompliance or a high deductible can be relevant to clinical treatment. Disabilities almost always go in the clinical record. “Patient is noncompliant with med X, so I am prescribing med Y which is only once a day.” “Patient has a high deductible so we will order an X-Ray instead of a CT”. If it’s relevant to treatment it can be shared with other doctors or released to the patient.
~Max
This indicates to me that you think every record we keep about a patient belongs to the patient. In my opinion only records that are relevant to the medical services we provide belong to the patient.
Just a few hypotheticals, to show you what I mean.
If a doctor thinks you are an asshole patient, you do not automatically have the right to force the doctor to say he or she thinks you are an asshole patient.
If a doctor writes in his personal diary, just before going to bed, that you were an asshole patient today, you do not automatically have the right to look at that section of the doctor’s personal diary.
If after you leave a doctor makes an offhand remark to staff that you are a trouble patient, you don’t automatically have the right to force said staff to tell you what the doctor said about you.
If the doctor, while on the phone with a colleague who is another doctor of yours, mentions that you are an asshole, you do not automatically have the right to somehow know about that remark.
If the doctor writes a memo asking a staff member to retrieve your medical record from storage, and refers to you as ‘crazy lady’ or ‘crazy guy’, you do not automatically have the right to know about that epithet.
If you believe the doctor’s opinion of you negatively affected your treatment, you might be entitled to force testimony or evidence regarding any of the above. But only within the framework of a malpractice lawsuit or ethics complaint: that evidence and testimony belongs to us, not you. It’s not part of your medical record unless we or a court say so. We don’t have to reveal our internal processes except as necessary for a court or ethics board to determine whether it affected our treatment of you or whether we violated ethical rules.
~Max