Bioethics Discussion Blog: The Dark Side of Medicine: Writing Lies into the Medical Record

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Monday, June 05, 2006

The Dark Side of Medicine: Writing Lies into the Medical Record

Resuming the topic of how the public views the practice of medicine, particularly issues that deal with the patient's medical record, I recently received the following e-mail from a visitor:


I was searching after reading my medical records and realizing that doctors lie on records via entering false information or excluding details. I was shocked to discover how records can be used to create the ‘truth’ rather than represent the truth. This knowledge has totally removed any faith I had in the medical community. It’s really creepy to fully grasp that doctors will do this. Even the specialist, who I completely trusted, left a detail off the OR records to protect a GP and must have allowed the GP to enter a false note in the records. There is no way the specialist would have missed the fact that the note was false. As a patient there isn’t a thing I can do to prove the records contain lies. I’m not even sure if it would matter if the lies were exposed because any group that functions like this is not going to change its ways from one complaint. It’s mind blowing to see the dark side of medicine and wonder how often records are used to protect doctors while causing great damage to the patient via loss of faith. Obviously the medical community has a major problem. The GP involved would likely suffer no negative feelings about lying but the specialist did not strike me as the type who could just lie and forget about it. Discovering that the medical community places value in ‘creating’ the truth over just telling the truth and letting the chips fall where they fall is disgusting.


Realistically, it is only rarely (really only as part of a court action or other legal documentation) that physicians are required to swear "the truth and only the truth" regarding what they have written in their patients' charts. The assumption is that what is written by the physician is the truth or at least is a faithful representation of what the physician knows about the patient in terms of history, physical examination, testing results, diagnosis and what the physician presented to the patient in terms of informed consent for treatment. The chart is not a novel but should be a clear documentation of the patient's care and therefore should be as accurate as clinically possible and truthful. To find a chart not meeting this standard should be highly discouraging to us all about the professional behavior. ..Maurice.

29 Comments:

At Monday, June 05, 2006 8:23:00 PM, Anonymous Moof said...

Dr. Bernstein, these last posts have been engaging in a completely different manner than any others so far. These have actually left me feeling anxious and upset.

I'd like to think that neither the blacklisting nor the dishonesty would be common ... but I'm not in a position to make that judgment.

Is this something you've seen very much of, Dr. Bernstein?

 
At Monday, June 05, 2006 9:32:00 PM, Blogger Maurice Bernstein, M.D. said...

Moof, I would hope too that frank blacklisting and intentional dishonesty (I guess dishonesty is always intentional) are rare behaviors but how can I really know? I have not participated in trying to prevent a physician from accepting a patient. I have been extra careful not to give in to patient requests and chart documentation for unwarrented disability partking permits or jury duty excuses. On the occasional Social Security disability evaluations I have performed, I have tried to present the facts and avoid the embellishments which some patients expect of me. Oh, Moof, life as a physician is sometimes difficult when the physician has fiduciary responsiblity for doing the best for a patient and is confronted by various system obstacles for appropriate diagnostic tests or necessary treatment. Therefore sometimes, though the facts in the chart are honest, physician may underline them a bit more than they deserve to gain attention. However, if you think that physicians are playing games with the systems, all you have to be is a physician who face patients clearly trying to do the same, as in my examples above. In response, some patient advocates might defend these patient behaviors as that of an ill person simply trying to get what is due to them. Physician responsibilities and patient concerns may not be able to be changed. Maybe healthcare systems have to be changed. ..Maurice.

 
At Tuesday, June 06, 2006 3:30:00 PM, Anonymous Bob Koepp said...

Sometimes physicians lie to "game the system" of second guessing imposed by (mis)managed care.

I once went to my physician seeking help with a mysterious "wandering pain" in my arm. My physician wanted to prescribe an anti-depressant to see if there would be any response, but to do so, she had "justify" her prescription to an HMO reviewer. She asked whether I ever thought about suicide. I laughed, and said "I work in bioethics, and spend quite a lot of time thinking about suicide, though not my own." She laughed back, and said, "OK, we'll call that passive suicidal ideation." The prescription was approved. Unfortunately, it didn't help with my pain.

 
At Wednesday, June 07, 2006 9:58:00 AM, Blogger Maurice Bernstein, M.D. said...

Bob, I don't intend for my comment here to be disparaging of your moral consistency, but, as an ethicist, how did you feel about your doctor writing in your chart "passive suicidal ideation" when you and she really knew it was a incorrect or at the least a purposefully ambiguous diagnosis and simply a gaming technique? As a physician, I have been torn between remaining strictly ethical, honest and clear in what I write in the chart and my responsibility to provide the best professional care I can provide to my patient. This doesn't mean giving in to my patient's personal whims but trying to overcome system obstacles in attempt to follow standards of medical care. For example, in your case, it would not be unreasonable medical practice to attempt to treat an obscure extremity dysesthesia with an anti-depressant. ..Maurice.

 
At Wednesday, June 07, 2006 10:27:00 AM, Anonymous Anonymous said...

The medical record seems to have many gray areas. Sometimes things aren't documented because of oversight; sometimes the record is deliberately tweaked. When you try to challenge or correct the information, it boils down to a case of "he said, she said." The patient invariably is the loser.

Several years ago I had a chemotherapy extravasation that escalated into a deep necrotic ulcer. The hospital medical record contained no mention of any problems at the time the drug was administered, even though I and a family member clearly saw the nurse was having problems with the IV. She actually had to lay down the syringe to fix the IV tubing, and when she removed the needle, the blistering and redness at the IV site were very noticeable.

The hospital swore up and down that the nurse couldn't possibly have known there was a problem. They based this on the fact there was no mention of it in the medical record. Their faith in the complete and total accuracy of the record is touching but misplaced. To this day, I'm still not sure whether they simply refused to believe the medical record could be falsified, or if they were just afraid to admit it to the patient.

In any case, I regard the medical record with an extremely jaundiced eye. Ideally, patients and physicians should review the record together before it's finalized, just to ensure everyone is on the same page. There should be fair due process to allow patients to challenge or correct what's in their record. That would require the system to give up some control, however, and I don't see that happening.

 
At Wednesday, June 07, 2006 10:37:00 AM, Blogger Hans G. Engel, M.D. said...

Often it is difficult to make medical decisions, particularly when your ethics become involved. There are always some physicians who put income over morals and enter incorrect data into an insurance report that might please the dishonest patient; claiming prolonged illness instead of recovery to cheat his employer; a hernia present for years, claimed to occur after obtaining a new insurance policy and approved for surgery by the knowing physician.
It may be unpleasant at times to deny a patient's request, but conviction and honesty is primary.

 
At Wednesday, June 07, 2006 5:36:00 PM, Anonymous Bob Koepp said...

Maurice -
I felt a bit, but just a bit, of ethical discomfort -- apparently not enough, though, to outweigh the physical discomfort that brought me to the clinic in the first place. I was aware that anti-depressants are sometimes prescribed for pain, and rationalilzed the physician's action with the assumption that she was just trying to minimize the amount of red tape she'd have to untangle. I can say that even though I went along with the ruse, I don’t think I’d advise others to act similarly. I view the episode as just one of many instances where I've been party to ethically questionable practices.

 
At Wednesday, June 07, 2006 9:33:00 PM, Blogger Maurice Bernstein, M.D. said...

I cannot be critical of your rationalization and your "go along" response. Your behavior is very "natural" in my eyes as a physician. You were ill with an unexplained symptom which produced discomfort and you took time out to go to a physician to get a diagnosis and relief. Your physician could provide no immediate diagnosis and advises an empirical approach to therapy and you look forward toward the chance for some relief of both the pain and some of the anxiety of the unknown. At this point, you and your physician are both faced with an obstacle at that moment, an irrational obstacle toward proper care. No amount of ethical rumination and excuses will change, then, what is "right" for you and your physician. You and she did what had to be done and though now, presumably free of personal physical distress, you would not recommend the same action to others, that advice now would be out of context and thus perhaps not appropriate.

When I wrote that I "don't give in to my patient's personal whims", I didn't mean to say that I ignore what they are asking nor disregarding the basis for their requests. They, as you had, often have an emotional and/or physical basis for their request. They are patients who are not well in one way or another and they are searching for some help. Not "giving in" on my part is knowledge that I may get in severe trouble by complying with their requests but I don't deny their needs. So, it ends up that I spend more time with them and try to talk out what makes up their motivations and see if there is another approach to help which I can also accept. This may not always be accepted by the patient but at least I feel comfortable that I tried.

Finally, Bob, don't you also feel as I do that medical ethics, moral and legal behavior is one thing to the emotionally and physically healthy ethicist but if an ethicist becomes significantly ill with many personal illness unknowns that are suddenly and unexpectantly developing, one should expect the appearance of a somewhat different ethical outlook as part of the consequences of that morbidity? I think that is just part of human nature. ..Maurice.

 
At Thursday, June 08, 2006 6:33:00 AM, Anonymous Bob Koepp said...

Maurice -
With regard to the question in your final paragraph, I agree that one's ethical _outlook_ is subject to change with changing circumstances, but I don't think that what is ethical changes along with the outlook. As I said, I was able to "rationalize" the subterfuge in which I participated, but I know perfectly well that rationalization isn't the same as justification. I was willing to tolerate some slippage in my own behavior -- that's the bare truth. Kant said that humanity is constructed of "crooked timber." My "go along" response illustrates his point perfectly.

 
At Thursday, June 08, 2006 8:29:00 AM, Blogger Maurice Bernstein, M.D. said...

Getting a bit more academic about ethics: Is ethics as a discipline really immutable? Isn't ethics fundamentally a consensus of society's "outlooks" as to what is right and not simply and totally based on the "straight timber" rigid teachings of specific people over the centuries? Isn't there something as democratic ethics? If not, then why not? I realize that what I am writing may sound to an ethicist as intellectually immature, but I never have held myself out as an ethicist and for the education of myself and my blog visitors, it might be valuable to discuss this point. ..Maurice.

 
At Thursday, June 08, 2006 9:41:00 AM, Anonymous Bob Koepp said...

Maurice -
You're asking a very difficult question about the objecivity of ethics. There are many very thoughtful people who would disagree, but I happen to think that ethics concerns objective truths about this world. I don't think we can turn to any authorities to tell us what is ethically right or wrong. And I don't think that consensus, even democratically reached consensus, is what determines the answer. All we can do is think, as clearly and critically and honestly and we are able, about how we should live. And then we should have the humility to admit that, in all probability, our best thoughts on the subject are not the last word.

 
At Friday, June 09, 2006 10:39:00 PM, Anonymous Anonymous said...

My 2 cents worth.

For me the purpose of the entries I make in the medical record is to allow myself to review that record 5 years later and have a fairly clear recall of the care provided.

Note I don't consider the medical record a narrative or even an accurate record. It's a recording device for my potential future use to allow recall.

I do realize that those not in direct patient care, administrators, patients and their families, lawyers, and courts/juries believe otherwise, but that's just not reality.

I need to see approximately 22 patients a day. If all the expected complete counseling and perfect complete documentation were performed I could see 6 to 8 patients and might as well close my practice.

 
At Thursday, June 29, 2006 8:22:00 PM, Anonymous Anonymous said...

My husband recently rec'd care at a local community hospital and the MD's documented conversations that never occurred. This included telling him they suspected he had occult malignancy, MEN-1, required an MRI of the brain for a pituitary tumor after telling us he had a low cortisol level (8 and 12 respectively - all within normal limits). When in fact, all they ever discussed was that his cortisol was low and wanted to do a co-syntropin test, which we declined, as we knew the level was within normal limits. We complained about this hospital to the State of MA Board of Health and the hospital and MDs are CLEARED because they documented this in the record, therefore it is regarded as truth and our conversations cannot be substantiated. We find it OUTRAGEOUS. They pressed and pressed him to get tests that to us were totally unnecessary and wanted no part of - he would only get care thru his primary care and hospitals we chose. He went to the local community hospital for what he thought was a minor problem but turned out he had severe anemia. Long story, many details omitted here but we are APPALLED that this occurred at all. So, in essence, you can document anything you want and it is regarded as fact. It's sad. It was obvious to us when we finally got the record that each doctor replicates the notes of another. At least 4 doctors replicated their notes near verbatim and the subject of "low cortisol" was discussed with only one of them -and that scantily. We found their tactics to take tests more to obtain money than any legitimate concern for necessity. We discussed the cortisol level with his PCP after his discharge (who's not part of that hospital's network) and his hematologist and both said there was no reason to question the cortisol levels. Yet if we had not said no, been acquiscent, they'd have ordered (and the insurance paid for) and my husband mercilessly put through a co-syntropin test and an MRI of the brain. It's all about money obviously!

 
At Tuesday, August 22, 2006 11:50:00 AM, Anonymous Anonymous said...

After admittedly leaving a weak spot in my dura when removing 2 cysts from my spine, my neurosurgeon lied on further hospital records when my dura ruptured 10 days post op. He blamed the rupture on the fact that I bent over about 45 degrees to push aside an empty cardboard box. Regardless that I had to bend at a more inclined angle to sit, this fool insisted that the dura would not have ruptured if I would have sat down at a 90 degree angle.

Within 12 hours after making repairs, the dura ruptured at the site of the repair. Though this happened in January/February, 2004, it has a profound effect on me to this very day. A good portion of the reason behind this is that the neurosurgeon lied on my hospital records. the ass was telling me one thing and recording something entirely diffferent.

I was so sick with meningitis and a staph infection caught at the hospital. My skin was an ash colored. Due to the excruciating pain I couldn't hold my head up long enough to take a pee (yes, they made me walk to the bathroom. I couldn't eat anything, nor could I withstand any sound or light & I had to remain flat on my back as to not let my brain fry, and the asshole LIED!!!! All in the name of protecting himself from a lawsuit. In addition, he had the audacity to bill my insurance for 2 more operations.

Between the 2nd & final operation, his associate who was on call released me. This was the greatest blessing because I was eating again & well taken care of at home. Thankfully this allowed me to become strong enough for the final operation. I was receiving meds through a PIC line & orally.

The following day (and week) was filled with phone calls (8-10 per day) from the jerk. I had my husband tell him to leave me alone. The ass begged my husband to bring me back to the hospital because I was so very sick. Since I couldn't find another neurosurgeon to take the case I told the ass to put together a plan that would guarantee me results and to call then. Plans were made and I told Esp. that I'd be at the hospital for the operation, which I was.


A couple months later I received the copy of the report that I had ordered. I about fell over when I read the report, which was to include the nurses records, but they somehow disappeared. The ass basically wrote that I was fine and dandy, responding well, with no leakage.problems or complaints.

He lied about EVERYTHING. Now my time to file a suit is up and I am left with no recourse. I'm also left with no trust or respect for those in the medical profession. Shame on anyone who would do such a thing. I could have died!

Mary

 
At Thursday, September 28, 2006 6:39:00 PM, Anonymous Anonymous said...

I find it very ironic, that after requesting and recieving a copy of my medical record for the first time in my life, (it became obvious that something very wrong had been entered in my record as doctors treated me like scum when they never had before), that I do a search on the internet for "medical record lies" and find a thread of opinion that seems to indicate this behavior is rare. I have found several inaccurate entries that imply bad things about me, as well as outright lies as well. I am now educating myself as fast as possible to see what I can do to correct this slander. In my case, it has to deal with pain management and a new doctor being assigned to me and others in that office. For the first time in my life, (I am 43 currently), I find myself amazed that someone can get away with this behavior, let alone cast an even more sinister light on the medical profession, hospitals and how they treat patients. I may have never encountered this up till now as I had good income and no serious medical problems to speak of, or, things have taken a turn for the worse and it's just my bad luck to be out of work with spinal problems at this time and not loaded with money to sue the stuffing out of these people and the lies they put in my chart. I will be following due process and putting my own statements in and all that. Lucky for me the doctors I have been seeing for the last 2 years had nothing like this to say so the latest doctor-switch thing looks pretty suspicious anyway to a discriminating eye, but if all they do is read the "latest" doctors report and copy it I am in deep trouble =(

For those of you reading this that think you can trust hospitals and doctors to do the right thing; all I can say is, do not trust your medical record. If I had not noticed some aberant behavior in the new specialists I had been referred to I would not have asked and I would have had NO idea how bad this last doctor was trying to make me look.
What a sad day for me. I am in pain, and fighting to see competent people that do not rush through things, and now I have to spend the little time I have out of bed dealing with this garbage on top of it all.
People brag we have the best medical care in the world, NOT if your poor.

 
At Wednesday, January 24, 2007 3:48:00 PM, Anonymous Cat said...

I am in luck! Today I found a glaring LIE on my post op medical record. The lie was that I presented to the doc who performed a vitrectomy as having DIPLOPIA. My luck stems from the fact that my vision is truly visable to all. I did not present with diplopia; he caused it by using a retrobulbar anesthetic rather than the general anesthetic I consented to. He probably started too soon; I jumped from the shock of the 25 gauge needle in my eye; he jabbed me again, causing him to "nicked a muscle..." or to cause myotoxicity in some other manner. In any case, at the age of 72, I needed to have strabismus operations on both eyes, since one set of eye muscles needed tightening, the other loosening. The doctor lied and I also believe he re wrote the entire page to CYA because through his negligence, he injured me.

 
At Saturday, December 01, 2007 9:54:00 PM, Anonymous Anonymous said...

I recently went into the OR for a half hr procedure to determine if my condition was healing. After waking up in post-op my physician informed me that I might be having a re-occurrence and if my test came back indicating that then I was going back in OR same day. much later that day I was brought back into the OR for another minor procedure. The anesthesiologist intubated me because I had crackers earlier.

I happened to read my med rec in which the physician indicated the need for the 2nd procedure BUT then he stated that he didn't do it at during the 1st procedure because "The patient requested they be notified first before doing anything else." That is not true. I have always been told what I will be doing in terms of my care. I have given carte blanch with whatever needs to be done.

I have great respect for him and we have a strong/good patient Dr relationship. It bothers me that I was represented as saying something I did not. I can only conclude that perhaps that was against the norm (OR twice in one day) and he felt the need to CYA. I never mentioned it to him nor will I. I have never told anyone else until now, anonymously in this blog and I never will.

I did tell a friend (before I saw my record) about that day. She is an OR nurse and commented that that was unusual because of anesthesia. I just shrugged it off then. But since seeing what he wrote it bothers me. I am fine and it worked and everything is good now.

I don't like being misrepresented though. I guess my total trust in him has a nick in it now.

Why would he have done this? Concerned about peer review of some sort?

I actually started to think well...maybe I did? But I know that would have been inconsistent with how I had been through the whole process. I was more like a lemming going with the flow because I am not the expert.

What do you think? Was this for insurance purposes or like I said some kind of review and he would be questioned?

 
At Saturday, December 01, 2007 11:19:00 PM, Blogger Maurice Bernstein, M.D. said...

Anonymous from today Dec 1 2007- If your doctor wrote that he didn't go ahead with the second procedure because he was awaiting your informed consent for the second procedure, this would seem appropriate unless you had clearly instructed him just before the first procedure that you wanted him to make a judgement regarding the necessity of surgery for the recurrence and if needed proceed to treat the recurrence without waking you up first. Now if you went back to the OR and under anesthesia and had a "minor procedure", which apparently was a "second procedure", the description of that procedure should have been written in the medical record. I can't be sure what occurred by your descriptions but in any event you should bring your concerns up to your surgeon so that you can understand what was actually performed and what was actually written in the chart.
You deserve to have a full explanation since you were the person on whom procedures were performed and you are the person who has a legal right to know and accept what was written in your medical record. For your information, the contents (written words) of the medical record is your property, the physical record itself belongs to your doctor and/or the hospital. ..Maurice.

 
At Sunday, December 02, 2007 9:13:00 AM, Anonymous Anonymous said...

Thank you for your timely response.

He has always done what needed to be done AND then afterward told me what was done. I can appreciate that another test may have been required to confirm his diagnosis. So why put it on me, that "I" requested being informed first, which I did not make that request. Also, before my knowledge of his saying that he didn't do the surgery first because he said I wanted to know first, I saw his partner about a month later (doctor away) for something else and a nurse was in the room. During the course of the conversation, I casually (in passing)mentioned having gone back into the OR that day and I caught the doctor and nurse shoot each other a look, the kind that says they disagree with something that was done, like they know something. I know that is subjective on my part but I picked up on that. Again, this was a couple of months before I read my medical report. So then after reading that and then remembering the look between them I started to feel like something wasn't right.

If he had written it the way you opened your response to me that would be fine but he clearly stated that he didn't do anything during the first procedure because "I" told him not to until he talked to me. Your way he is taking responsibility for not going ahead but what I read puts it on me. Maybe I am taking his words too seriously.

I want to be wrong and I don't want there to be a nick in my trust for him.

Most important is that I am healthy and doing well. He IS an excellent doctor.

 
At Sunday, June 22, 2008 9:10:00 PM, Anonymous Anonymous said...

I realize there have been no recent threads on this topic, but I wanted to see what you think of something that has happened to me.

I had seen an MD, about 8-10 different appointments over a period of 20 months. Although I was diagnosed by her with having a rare fatal disease, instead of starting treatment ASAP, I went to the medical institution specializing in this rare disease. They told me I was misdiagnosed, and I did not have this fatal disease. In fact, had I gone through treatment, that may have been fatal to me.

Anyway, back to her to figure out what is causing all my symptoms, etc.

I provoked her in a huge way, when I asked her why my bone marrow biopsy results are still not ready 11 days after my most recent biopsy. She told me I needed a lymph node biopsy. I told her I had an appointment with an ENT the next day, and I would talk to him about doing the biopsy.

Well, to make a long story short, my medical record now contains an allegation that I suffer from Munchausen's. She knew I had a pending Social Security disability case. Well, this sure has made a difficult situation so much worse.

So -- where is the belief that a Physician is to do not "harm?" The damage she has caused me is huge. Furthermore, I can not even get treatment at this medical institution.

I have had to transfer my medical care, elsewhere, which further causes one to wonder if I truly am a Munchausen's case. But -- I am not.

What should I do? How do I get my medical record cleared of these false allegations? The damage done to my Social Security disability case may not be able to be undone.

Just a side note, there were four medical students in the room when this incident started, and two medical students in the room when it escalated into her stating she would "take care of me." She did.

Should I go to the Board of Healing Arts in the state where she practices? Can I find out the names of the students who observed this exchange, and subopena them to testify at my SSD hearing?

It's hard enough to deal with a chronic long term illness, but having to fight a battle like this with a Physician you thought you could trust -- is even worse.

Thanks for your feedback.

 
At Sunday, June 22, 2008 10:39:00 PM, Blogger Maurice Bernstein, M.D. said...

To Anonymous of today June 22 2008--check with your lawyer. Depending on the laws in your area, you may have the right to make corrections of gross errors in your chart. In addition, your case is complex enough to warrent a lawyer in your Social Security Disability hearing. ..Maurice.

 
At Sunday, January 06, 2013 12:35:00 AM, Anonymous Anonymous said...

I have a disturbing situation I would like your advice on. In Jan. 7, 2012, I was at home with my 4 yr.old daughter, putting away some boxes of Christmas decorations in my attic. The stairs to the attic are very steep, turn at the top, poorly lit, and have no railing. On my way down, I had both hands on either sides of the stair well and I lost my balance and fell head first all the way to the floor. I yelled for my daughter to call 911, because I couldn't get up and the next thing I remember, I was in the hospital. Turns out I had became unconscious and my fiance came home 5hrs. later to me on the floor. My daughter was holding the cell phone in her hand with 911 dialed but didn't know to press send. I had been laying in a contorted position that cut the circulation off to my legs. The muscle tissue in my legs died and got into my blood stream and clogged up my kidneys causing renal failure. I was told I would have died in 40 more min. had I not been found. To make a really long story shorter, my urine tested positive for cocaine. The doctor asked me if I had been using drugs when I fell. I told him NO. I had went to a bachelorette party on Jan. 5 with a group of old friends. We all had gone to college together and back then would sometimes use the drug on seldom basis. Well one of the women there that night had some and we all did some. Now I am now 36 and I hadn't been involved with that type of behavior for many years. When I was told that I may be on dialysis for the rest of my life I filed for disability from my hospital bed. I had both my legs cut open from the knee down in order to save them. I obtained my records and what I read enraged me. The doctor who saw me first in the ER and took my initial statement wrote, "35yr. old cocaine addict came in after a fall down a flight of stairs while using cocaine." What the hell is that!! and after that every doctor who saw me in that hospital treated me poorly and also continued what he wrote about me being a cocaine addict. Now, I'm not trying to make lite of my behavior on the 5th but I was not using cocaine when I fell!!! It was a straight out lie! What would he gain from saying that? Because of that statement, about 1/3 of the records from the 3wks there say something about cocaine or addict. There was no evidence what so ever to support that statement. In all of my medical history, not one doctor that I've ever seen has anything about me saying that I'm a cocaine addict and I've been a patient there since birth. It completely ruined my life. I wasn't able to get pain meds when I left the hospital so I didn't walk again until June. I was in renal failure until April but disability must have missed that fact due to all of the slander about drugs on every page. How can a doctor just make up his own story as to what happened to me and now it's part of my permanent medical record? Can I sue? KF

 
At Sunday, January 06, 2013 10:16:00 AM, Blogger Maurice Bernstein, M.D. said...

KF, you present a sad personal example of the consequences of a physician writing a generalization in a chart without describing the supporting facts. This, unfortunately, is not uncommon when the generalization is used in the opening statement.

I am not a lawyer and cannot inform you about a suit but I think you should check with a lawyer regarding the legal opportunity to change the charting error. ..Maurice.

 
At Monday, January 27, 2014 8:05:00 PM, Blogger Maurice Bernstein, M.D. said...

PA wrote the following comment today. I have edited out descriptions which might identify the specific doctor involved. ..Maurice.

I went in for a medically recommended breast reduction. I was fit and athletic. My bra size was 32 DDDD. I asked to have the excess skin removed, and the breast lifted to lighten my breasts, and give me some structural relief. I have been fitted for bras throughout the decades at Nordstrom. I consistently measured 32 DDDD (32 G). I had a hard time even finding bras in that size, (petite frame, very large cup), and often had to make do with a 32 DDD (32 F). A 32 DDD size bra didn't support me fully, and my breast tissue spilled over the top of the cup, which was uncomfortable and embarrassing. I tried to wear a 34 DD (and other sizes because they can vary slightly due to manufacturer), but the 32 band width and DDDD cup was my size. 32 DDDD (32 G). A reasonable breast reduction (excising the skin, and lifting the breast) is what I asked for clearly and specifically; verbally and in writing. My physician wrote a letter stating that I was a 32 DDDD (32 G). I wrote a letter stating that I was a 32 DDDD (32 G). I told the Plastic Surgeon that I was a 32 DDDD (32 G). I told him how hard it was to find my size, and that I sometimes had to stuff my breast tissue into a 32 DDD. I told him I'd like to retain as much of my breast tissue as possible, and my choice would be to end up a regular D cup. Well, after he resected me down to a B cup… and here's the kicker: HE SUCTIONED OUT MY BUTTOCK AND MULTIPLE OTHER AREAS OF MY BODY AGAINST NEED AND CONSENT LEAVING ME DISABLED, DISFIGURED, AND SLOWLY DYING IN EXCRUCIATING PAIN, I asked for my medical records to be released. It was then that I saw that this brilliant surgeon wrote in the consultation notes "She states that she wears a 32 DD by bras size…" (2 sizes smaller than I was. 2 sizes smaller than I said I was verbally and in writing). He went on in his consultation notes to state that I was a D cup. (3 sizes smaller… you get the point). Another plastic surgeon I consulted with correctly notated my size in his notes. I WORE a 32 DDDD (32 G). My physician stated it in writing. It would take a small book to tell you how inept and fabricated the surgeon's records are. The kicker is that I came out of surgery convulsing, in mind-boggling pain. Beyond what I can explain to you. It only gets worse daily. I didn't realize at that point that this guy had done extreme liposuction from my shins on up (against anatomical suitability and against my consent) that suctioned out my buttock, destroyed the matrix of my body, and grafted my skin to my body. This guy is in and he is often referred to by oncologists as a "Reconstructive Expert." If I had known as a patient that I should double check my records before surgery to see if the Reconstructive Breast Specialist (that my physician raved about), couldn't even get my breast size right, (which was the focus of the surgery) well then, I would have known not to put my life in his hands! Patients need to see their records, and have the ultimate say. I didn't know I needed to do that, and I went with the wrong surgeon who destroyed my body, health, and life. But the guy wasn't done with his lies yet. Without a buttock (which was literally suctioned out without my knowledge while I was under anesthesia), and with my skin grafted over a great deal of my body, I can't sit or move normally, and I lost my business and all of my savings were gone. The Reconstructive Breast Expert in . told SSI that I "healed without any medical complications" thus, preventing me from getting even a small amount of money for groceries…. after he disabled me! I'm on SSI now, but I had to fight for it. I got to other doctors who saw my body and were horrified. They said things like: "You were butchered and made an invalid."

 
At Sunday, March 02, 2014 10:44:00 AM, Anonymous Anonymous said...

OMG can I relate. My chart is so full of lies it is terrifying.
Last winter I enterred an ER for depression. I am a type one diabetic and at the time of admission my blood sugar was around 80- perfectly normal. The ER doctor took away about 3/4 of my daily insulin doses. As a result, my blood sugar was so high when I left that my meter could not even read the number. I was over 600.
My chart says I was "treated for high blood sugar." Huh?! Even when I was over 400, the ER dr. refused to give me more insulin. She ignored what I said I needed as well as my outside dr's orders.
I tried to get that part of my record amended, and the dr. refused. It boggles my mind how unaccountable doctors seem to be.
The hospital's patient advocate was useless (I should have known given she works FOR the hospital). State medical board did nothing. I can think of no LESS safe place for me than the hospital- ironic.
Elise

 
At Sunday, March 09, 2014 1:03:00 PM, Anonymous Anonymous said...

I am currently searching for an attorney to file a defamation suit against a large hospital. My husband went into respiratory arrest three days after a quadruple bypass Dec. 2013. He was resuscitated, thank God! I (wife) have suffered a lot of post-anxiety and stress after witnessing the whole thing. Imagine my horror to read in his medical records that I am to blame for this incident!!! I am livid!! I knew a couple of nurses didn't like that I was always in the room, questioning meds, etc., but I was always kind in doing so. Still, they didn't like it. What better way to "get back" at me than to use me as the scapegoat for the post-surgery neglect!! The entire paragraph about his arrest is one lie after another. Even stating I had to be removed from the room-I was there the entire time and have the chaplain of the hospital as a witness. I am appalled and disgusted by these people who have too damn much "power" and can write whatever they choose and the patient and/or loved ones are just stuck. There needs to be laws against this abuse of power!!

 
At Monday, August 11, 2014 6:47:00 PM, Anonymous Anonymous said...

I have a 3 year old with a severe brachial plexus birth injury. My son and I both suffered alot at birth. We never thought our first born wouldve suffered a severe injury and also could've died do to a doctors selfishness, I didn't know but a nurse and a learning doctors delivered my son, I was a diabetic my son was already too big because of my sugar. I was 36 weeks and my water broke. I wasnt opening so the give me meds for 2 days to force birth. They told me the baby is fine and that their was no need to run into surgery. After 3 days in bed with severe labor pains I wanted a c section. I told them to get a c section ready however when I was ready for csection at 6pm the learning doctor and nurse did a exam and said was I was fully open and that their is no need for surgery. I started pushing and at this time of my life I just turned 20 years old and I was getting ready to have a child with my husband. My doctor was busy giving to other children. Maybe the didn't care cuz of my race or religion. I pushed from 6 to 10.26pm when my son was born. They pulled the vacuum 6 times over and over again cuz he was stuck. He almost died. His breathing level was 10, with severe brachial plexus injury on this right hand. He was in isu for a month. It was the longest month in my life. I never left one day to go home. However I got a lawyer and wanted to fight for the son and the severe damage the caused to his life but they but I refused a c section in my "Medical record". I had surgery before and I never refused any surgery. How can they do that and put false information in my medical record.

 
At Tuesday, August 12, 2014 7:55:00 PM, Blogger Maurice Bernstein, M.D. said...

Obviously the doctor didn't write your request for a C-section in the chart when informed the doctor of your desires. Patient's requests are just as important to write as a progress note as the patient's physical finding at the time. For the doctor to write in the chart that you refused should also explain what and when c-section was offered and why it was offered. It is bad enough the consequences of the birth but to face the documenting an untruth represents an added injury. ..Maurice.

 
At Friday, October 17, 2014 8:34:00 PM, Anonymous Anonymous said...

It has been my experience, personal and otherwise, that many doctors write lies into medical records on a fairly consistent basis.

What happens when you go to another doctor with these "doctored" medical records is yet another disturbing problem. If the first doctor you see totally f*&ks up the diagnosis, treatment, whatever; and if you make the MISTAKE of letting subsequent doctors see what the 1st doctor wrote about you, more than likely they will automatically assume that doctor's word as "gospel", and that you are either lying or hysterical.

Basically, it is professional whitewashing of other doctors wholesale mistakes lies and screw ups. For doctors, it's the 11th commandment, "thou shalt not speak ill of other doctors' diagnosis, no matter how egregious or outrageous".

Best advice, take a recording device with you, and NEVER allow any new doctor to see a "bad doctor's" notes about you!!!!

Patrick L

 

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