Under HIPAA, a patient has the right to ask for a correction in the chart and to create documentation and have it included in the chart. I did this last week when I saw something coded incorrectly, and in the past I’ve written a letter, now in that medical record, describing an ex-doctor’s failure to follow up on something according to standard of practice, and the medical consequences of this lack of follow up. This was necessary for filling in the sequence of events.
ETA: If you want to complain, the sequence is the professional->the clinic manager or omsbud->the licensing board. Complaints about a doctor in your own chart would just make the next doctor wary of you.
Note also that descriptions like “unkempt/disheveled” or “obese” or “morbidly obese” will make it into the clinical record. So will suspicions of malingering, excessive anxiety, and hypochondria. These kinds of descriptions are not secret at all and will be shared with everybody who gets a copy of records, including the patient who is supposed to be told so much to their face, during the visit.
OMG. Your like a cop, talking a load of garbage.
If you live in any major city in America your doctor and any of your specialist doctors and even the doctor in the 5 area hospitals are ALL either in the same integrated health system or somehow connected in the the local private health care network. None doctors in this network have a private computer system to kept their own secret notes of the patients they’ve seen private and not able to be seen by any other doctors or medical people in the very very large private health care system.
You know now that there may be a secret note somewhere in your file that you are a trouble maker and a tattletaler. When you go to a new doctor he will see the note about you.
Yes, well, that is what happens if all your doctors are part of the same group. They may all share the same opinion of you. They might all talk unfavorably about you during lunch breaks too, without violating any law.
If a doctor makes a note about you on your file on your medical records, that other doctors that you go to in the future are going to see, then they should be legally forced to let the patients see it or know about it.
If it’s that important for a doctor to write it down, then he should address it with the patient.
For what purpose did this doctor have to inform other doctors that this patient was very pleasant gentleman? The doctors spend 5 minutes with you in the room during the visit and was this what he spent his time on "guessing how pleasant or unpleasant the person was?
@Ron You seem really, really bent out of shape that you might not know everything the docs who have treated you may have thought or felt. Why is that? Did you have a bad experience? Are you convinced there’s important medical information–say, that cancer was detected–and it’s been kept hidden from you? Do you think you’re a difficult patient?Or is it just that you can’t stand the idea that someone might write something negative about you, true or not?
Unfortunately, I’ve had to consult dozens of doctors, some excellent, some good, a few incompetent. (I’ve “fired” the incompetent ones.) I’ve never felt the need to know what they thought of me personally, partly because I don’t act like an ass but mostly because it’s not relevant. If I have the doc’s diagnosis, prognosis, and test results, why do I need to know what “secrets” she’s writing on my chart? Why do you?
Nor should nurses, pharmacists, etc. but that’s what’s going on. It’s all about the bottom line, and the decisions are almost never made by people who are directly affected by them.
For a while, a medical practice across the country from me somehow had my private work fax number listed as the number for some provider. I saw a lot of medical records.
(I wrote back and told them of the error. I called them and told them of the error. It took quite a while to purge my number from their system, however.)
Most of those records were very bland. “Patient was well nourished” did show up. So did lots of details about tests actually performed and procedures done. Once i saw a note about a patient who was not compliant with a medical recommendation.
I never saw anything about a patient being an asshole. Nor about being a pleasant gentleman, for that matter. It was an orthopedic practice and several of the records were of teenagers. I bet some of them were assholes. But not enough so to be clinically relevant.
Also, my father was a doctor, and used to talk about his patients at the dinner table. This was before HIPPA, i suppose that’s probably illegal today. But he often talked about how nice a patient was, and how tragic the illness was. I can only remember one story about a belligerent patient. It was an old lady who kicked a doctor across the room. But the point of that story was that the doctor had been an asshole, and provoked her, and got his comeuppance.
I once had an ophthalmologist who, after every visit, would write at the top of my chart: “Patient’s rosacea is a little worse today” or “Patient’s rosacea is improving” or “Patient’s rosacea has spread” before getting on with my eye issues.
My mom had an MRI a little while ago and while lab reports are immediately available, radiology reports are embargoed for 10 days so the ordering physician can review it first.
Thought we had a three troll limit on resurrected threads, but I probably imagined that.
FWIW, though most patients are pleasant enough I rarely write that in the chart either. A few doctors use the term a lot but most doctors don’t seem to do this routinely in Canada.
AFAIK this isn’t required by any rules, it’s just that the people who wrote the software did it that way… we’ve had an open ticket to fix this bug in our EHR for about eight years now.
Note that patients have always been allowed to request results directly from the lab, and I think this much is required by law since the late '90s. Even today you can sign up for eg: a Quest Diagnostics account to view your results immediately.
