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





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.


At Monday, June 05, 2006 8:23:00 PM, Anonymous Anonymous 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 Anonymous 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 Anonymous 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 Anonymous 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 Anonymous 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!


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 Anonymous 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.

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

At Thursday, January 22, 2015 7:39:00 PM, Anonymous Anonymous said...

How about a physician hired by the company you work for? In our case, my husband was exposed to a hazardous chemical at work and was asked to stay on for 4 extra hours to assist in the clean up of the chemical. When he was authorized to go to their doctor, he agreed the damage was work related, then after speaking with the company leaders, changed his mind so my husband was denied worker's comp, by saying it was a preexisting condition. He got caught in that lie during depositions when our side showed proof that he signed off there were NO prior conditions only 8 months prior for his yearly work physical! What can we do about this? Because he was denied workers comp, we lost our home and children!

At Friday, September 25, 2015 7:30:00 PM, Blogger Duh said...

I recently called my doctor requesting to be seen for paeuresis (shy bladder.) i explained that i was having to undergo drug tests and in order for them to make accomodations for my condition, I would have to have a note. Well, they wrote in my chart that I was requesting a letter to get out of drug testing altogether! This makes me look like a horrible patient! They totally twisted my words! I finally got a referal to a urologist, but i fear that they are going to tell him or her that i'm just looking to get out of drug testing!

At Sunday, October 04, 2015 5:49:00 PM, Anonymous Anonymous said...

I know from personal experience that, as an institution anyway, the medical field is nothing short of sociopathic. How ironic given that their main task is supposed to be helping and healing.

At Monday, October 26, 2015 12:40:00 AM, Anonymous Anonymous said...

Please, this is extremely important; where does a patient turn to bring accuracy to their medical records? There must be some way to stop & to correct this. (No, there are no funds to hire an attorney.)
It seems as if, by pointing out errors, it only gets them perpetuated, seemingly on purpose. It is bad; incorrect entries, &/or omissions, things repeatedly ignored & left put, tests left out, procedures messed up or done wrong never mentioned, erroneous claims that led to expensive tests & treatments, major topics ignored as if never addressed. Is this intentional, ineptness?, sloppiness, ego? It really does seem as if much is intentional acts of c.y.a. It seems almost passive-aggressive, & underhanded harassment. Aren't these records, a patient's permanent medical records, legal documents, supposed to reflect the truth? If errors are found, is there a way to honestly correct them? There seems to be no over-sight or quality of truth, & no place or no one for the patient to get them corrected. (Addendum's lost in the shuffle, never to be read.) Errors are not corrected, and are continued & carry-over to new doctors as if a blatant act of revenge against the patient for speaking up. Please, I truly hope you will be able to direct me in a helpful direction. kp

At Monday, October 26, 2015 9:38:00 AM, Blogger Maurice Bernstein, M.D. said...

After communicating with the physicians who wrote the medical records, the next step would be to take the matter to you state medical licensing board if in the United States or if you are in another country, to that country's medical licensing board. These boards are responsible for assuring professional behavior of physicians to the public. I hope this advice helps. ..Maurice.

At Sunday, November 29, 2015 12:45:00 PM, Anonymous Anonymous said...

Did you get any response to your questions? I would also like to know...going through same thing here. Thanks

At Sunday, November 29, 2015 1:51:00 PM, Blogger Maurice Bernstein, M.D. said...

So far, no followup by kp. I too would be interested. ..Maurice.

At Monday, February 01, 2016 7:47:00 PM, Anonymous Anonymous said...

I am looking for a way to 'require' a physician to at least report my reaction to the STS foam injection that I received recently. My medical record for that day says everything went normally, although it definitely did not. I went into seizures later that day that resulted with eight days of hospitalization including short-term paralysis, rehab and unknown complications at this time. I cannot drive for at least six months. When I went back to that physician for follow up ultrasound and evaluation, I was seen by the ARNP and I told her all tests done on me at the hospital had eliminated every other cause, except for the reaction to the injection done that day (which the hospital physician indicated as the cause of the seizures). When I talked to the doctor who administered the injection while I was in the hospital, I asked him to contact the hospital physician to assist with determining what happened to me, he said very little chance it could be the STS (I sent my husband out to get a lottery ticket). He didn't contact the hospital, and my report for the day of the injection didn't say that my blood pressure shot up high and I had a visual disturbance (migraine aura) that they gave me an ice pack for when I left after my blood pressure came down. I told the ARNP they had a moral obligation to file a correct report for the information to get to the manufacturer for the protection of future patients, even if the complication is rare. SW

At Saturday, May 07, 2016 4:05:00 PM, Anonymous Anonymous said...

This happens all the time. I saw a specialist on recommendation from my general practitioner for a high white blood cell count. It wasn't terribly high and I have autoimmune arthritis, so I wasn't very concerned, but why not hear the dr out. I went, the dr wanted to run tons of tests and I kindly declined until I spoke with my arthritis specialist at UofM. That ticked him off. He wanted me to drop some dimes. Then a few years later he wrote I had been diagnosed with anxiety and other mental issues. Last time I checked an oncologist shouldn't diagnose those problems. Well now I can't get life insurance due to having a combination of arthritis and related medications with the addition to the oncologists diagnosis of mental illness. Local hospital who hired him won't remove them from my record. I have tried for over a year. Maybe if I sue the Dr. I will have my due process. That will only cost me thousands. Should of just let him charge all those tests, would have been cheaper. Also my pediatrician tried to bill me for an circumcision that never occurred. Another ethical concern for Drs, circumcision. An elective surgery to prevent a problem that may never occur. Drs preform the extremely painful surgery without the baby's consent. There should be Drs boycotting the practice in the streets, but there is too much money involved in the practice.

At Monday, May 16, 2016 11:21:00 AM, Anonymous Anonymous said...

My doctor's (GP) nurse lied in my file, once that I have been made aware of though I'm sure there are many other instances, and I found out because she tried to sabotage my urine sample on my last visit. This woman has been messing with my file and lying to the doctor about me, and many other patients, for years but I couldn't prove that she was lying about me, until now.
I can prove this with the help of my pharmacist and, by the grace of God, my wife, who's urine sample she switched with mine, submitting urine at another clinic that treats a specialized issue of hers less than 24 hours before the samples were submitted at the doctor's office. This sample will show that the sample at the doctor's office attributed to her file couldn't have been hers (My wife's urine on my file made it appear I was "dirty")
Even if she contaminated my urine with my wife's to make me look as though I were "dirty", as opposed to just switching the results, I can prove the urine has been tampered with because my wife is a secretor, she always has blood in her urine, and I'm not.
The woman shouldn't be taking care of other people's health until she takes care of her mental health.
She's sick and she's also stupid.
My wife, on the other hand, is a genius and a problem solver.
I'll be reporting her to the disciplinary board at the nursing college as well as reporting my doctor to the physician's disciplinary board as she was told about what this woman constantly lying and did nothing about her.

At Friday, July 08, 2016 7:03:00 PM, Anonymous Anonymous said...

Sorry that happened to you. Glad your still here. Agree with you 100%. What jerks and liars to put something like that in your medical records....

At Monday, October 31, 2016 8:47:00 AM, Anonymous Anonymous said...


At Monday, December 05, 2016 9:21:00 AM, Anonymous Colleen said...

WOW! That is utterly outrageous! I got here because I have a question of my own, but YOUR story is SCARY! I have had more than one incident of doctors blatantly entering total lies in my records for reasons unknown myself and I am LIVID. Good luck and God bless, my friend. I'm still in shock that this goes on as frequently as it does! Take care, all.

At Wednesday, August 23, 2017 10:58:00 AM, Blogger Maurice Bernstein, M.D. said...

Anonymous wrote the following today. ..Maurice.

I had a PCP that is the age of my son 37 yrs old. I never should have stayed with this practice and regard the institution as unreliable and not trustworthy. I should have got out when I was forced to pick my 3rd PCP from the practice. I stayed because it was convenient to and from my job labs in same building. Never dot your gut instinct over convenience!! This was the 3rd PCP as all the others left for better positions. I have worked in the medical field for over 20 yrs and am not someone who is ignorant of my medical problems and symptoms. I have had severe stomach pain back pain for over 10 yes with vomiting. I have Barrett Syndrome. Over ten years ago I had H-Plyori that I believe destroyed my heath to this day. This PCP would just continue to refer me to specialists within the system I never got any answers but the findings on the CTS and tests indicated enlarged left adrenal gland and kidney cyst with hernias and IBS and more I will not list. I don't take pain meds as my stomach cannot tolerate them, she was rude and condescending to me, brushed off my concerns and told me I had been all over the place for my problems and needed to stay with one MD. I called their customer service department several times to complain. I received a letter dumping me from their care and refusing me any of their services in the future. On the last clinic note I sent for she spewed so many lies I am furious and astounded. I had no idea this was so commonplace!! She put on my report that I have a long history of chronic Hep. I have and can prove that I do not have any history of this or any other of the STDs!!! I keep trying to find a lawyer to deal with this but no one will take it. I realize you need to have plenty of cash to even deal with this problem! I sent a letter certified with a return receipt asking to verify where she got this dx in my medical record? I have not heard back, she also summarized on her last clinic note to appear that she reviewed my extensive MR and listed my conditions as normal and my test results as normal when they are clearly not normal! I now have lost my job and have no insurance. I received the dump letter from the CEO of the who was on the board of a different hospital where I worked.
Shortly after I received the letter they cut my job position? It seems to much of a coincidence to me or extreme bad luck!! How can this happen? I am blown away by it all!! How can this be?? I am simply floored!! Is the State Medical Board the only answer. Don't they protect their own.

At Thursday, August 24, 2017 8:08:00 PM, Anonymous Anonymous said...

I see your reasoning. Medical records are looked at by other MDS and insurance companies. It affects the patient in the long term. I find you comment uncaring, it's obviously the way you get through your day. It's obvious you see your patients in the end as just another number. I worked in a hospital, no longer but I saw this every day, it's all about the numbers and not the patient. It's a mindless grind and dregrades the patient and the physician in the end.

At Thursday, August 24, 2017 8:22:00 PM, Anonymous Anonymous said...

Patrick I did the recording of a conversation. I made the mistake of telling the complaint service. They dropped me from receiving care. Literally dumped me! I looked up the laws regarding recording conversations without the other persons knowledge. You have to look at your state. Some states allow some do not. My state does not. You can go to jail or receive a fine up to 5000.00. They outright lied about everything and I have it recorded but can do nothing about it!!!

At Thursday, August 24, 2017 9:23:00 PM, Blogger Maurice Bernstein, M.D. said...

Please, maintain the continuity of the discussion here, if you are signed on to as "Anonymous", please end your comment with some pseudonym (first name, initials or some other pseudonym) but keep the pseudonym consistent on repeat postings. Thanks. ..Maurice.

At Tuesday, October 17, 2017 3:39:00 AM, Anonymous Anonymous said...

Hi Advice welcomed please.. While I was in hospital I was in a lot of pain, i had been in for several days spinal herniations, i was cared for by many fantastic staff then one night a rude and confrontational auxiallary bully came on to the shift with a very young and easily led nurse, the auxiallary refused to bring me ice to sooth my immflamation and then put me on a bed pan without drawing the curtains...the night got more distressing because i was in so much pain and was been treated by hostile staff. I pointed out the poor practice and i am not usually brave enought to say anything but at 6am when no pain relief had come, no ice, no dignity, care or respect i felt compelled to stick up for myself,....oh and thats not to mention being called a loser for crying in pain.The nurse didnt take my direct complaint well and, they said my ice pack was a slip hazard and refused and i contested that with the nurse and complained about it to her....only for two auxiallaries to come in and pretend to slip and then laugh about it. At that point I rang my husband upset, i asked him to come, it wasnt visiting times so he didnt see the urgency they were listening and were laughing about this to each other within my ear shot to probably cause more distress, my herat was racing and as i already had a heart condition i asked the nurse to take my blood pressure she said there was no point as it would be high as i was upset and this would just worry me further isaid please take it anyway you dont need to tell me... after taking it she ran away crying saying it was fine but she was sobbing for some time, i could hear her. at 7.00 i was so relieved that fresh staff would come on duty i was just willing time on. i thought i will sleep when i know i am safe and i have had some pain reliefso every second felt like a life 7am the new staff came on and the nurse came to me and aid please can i take your blood pressure i was just dropping of to sleep but agreed she put the cuff on then left the machine walking away not looking at it something didnt feel right and then i realised she was not doing it for real and just let it expand and expand, it was so inflatated it was unravelling and unravelling, I held out and tried to show no pain in defiance to this was abuse and when i could take it not more I undid the last bit of velcro that held it on and threw it off, the nurse then came to my bedside and smiled and said oh i thought you wanted your blood pressure done?
I then remain on the ward for a further 5 days but i conciously shut myself down and didnt speak, eat or drink. I just closed my eyes and tried with all my might to pretend i wasnt there, kit took great determination, i ignored all stimuli, i could liken it to deep meditation. as soon as i got home i was fine. back to myself not scared. Back in aloving caring environment my husband had to fight to get me released they didnt want to.
i recently did a subject request and that night they wrote i was upset and parnoid not happy with treatment and that they explained they were busy to me, and that i wouldnt accept it.
they also put that it was the same night nurse did my blood pressure which it wasnt which to me was the final straw as it was the new staff.
in my notes this is falsified.
what if anything can i do?

any advice would be very gratefully recieved it feels like the nhs machine is too big to fight and what they write as accepted as pure fact and truth, the whole truth and nothing but the truth....but it is far from it! Jade

At Sunday, February 25, 2018 8:36:00 AM, Anonymous Anonymous said...

Sadly it happens a lot.

It's happened to me and many people I know of.

And they did make a promise. To first do no harm. If lying in medical records isn't harmful I don't know what is.

In our family's case it has resulted in diagnostic delay to a vulnerable child, false reports going to other professionals resulting in multiple diagnostic failures, healthcare failures, disability discrimination and more.

These people are vile and truly don't care about what they are doing, I have evidence of a GP acting entirely maliciously and when I changed practices, he contacted the new GP to lie about me and the new GP then carried on the diagnostic failure saga. It's an old boys network and the majority are fully prepared to cover for one another and lie. I changed to another GP in the same practice, who was allegedly caring and lovely. She then also failed to make referrals, lied and breached data protection. It's absolutely rife.

At Sunday, February 25, 2018 8:51:00 AM, Anonymous Anonymous said...

But surely the doctor should have proof of the alleged refusal likewise and without it be held guilty.

At Friday, March 16, 2018 3:43:00 PM, Blogger Giftbearer said...

So that I don’t run out of space I’m going to add my comments in several separate parts. This abusive charting practice is a rampant problem in the medical system and none of the so-called "regulatory agencies" really regulate corrupt doctors and corporations they work for. I proved this in December 2015 when I was abused by an on-call neurologist in the ER because of an incomplete medical record from a previous hospitalization (at a different hospital) for severe near syncope and systemic weakness.

The man interrogated me in a very accusatory manner (as his resident and the ER doctor looked on), was overly rough during his "neuro exam" which ended up as a beating, posited that there was "nothing neurologically wrong" and that it must be "psychological", then had his resident come back into the room by herself afterwards and plop her butt hard on my left foot to see if I was faking. I'd told him he was wrong and not to jump to conclusions, and that he must not write any such thing in my chart as I had long-term positive doctor/patient relationships there and what does he do but write worse than what he'd said to my face, painting me pretty much as though I were either a nut or a criminal.

At Friday, March 16, 2018 3:45:00 PM, Blogger Giftbearer said...

Part 2.
Not only did I file an internal complaint with the healthcare system itself, but also a police report, Medical Board grievance, and one with every regulatory agency with jurisdiction all the way up to the Office of Civil Rights! (The GA. Medical Board claimed it lacked jurisdiction over the on-call neurologist who was licensed in this state because he worked for this medical care corporation). Sorry, but in what universe is a doctor not under the jurisdiction of the state that licenses him? I called BS on the guy who told me this but regardless, he stated “the board’s decision” was “final”.

What I was subjected to was in the true sense of the word a hate crime, (because I was a patient, and because it was assumed I was somehow hysterical; a judgment disproportionately meted out onto women) yet the response from every agency was that they base investigations "solely on what's written in the medical record", (by the perpetrator(s), so my grievances, all filed through proper channels, were summarily dismissed with no consequences imposed upon those who committed and colluded to legitimize these acts and proceeded to cover them up.

The healthcare system that went after me as a corporation to cover up the malfeasances of their employees is the largest in Georgia and pretty much controls the entire field of medicine in this state. Almost every "independent" medical practice outside of there either uses their labs, radiology, has done residency there, and/or refer patients back and forth, so I was screwed once they kicked me out as their Chief Medical Officer put in writing "because we are unable to meet your expectations." Yeah, patients don't expect that kind of cruel treatment when they go for medical care, and if being treated humanely is "unreasonable" then what kind of world is this?

At Friday, March 16, 2018 3:48:00 PM, Blogger Giftbearer said...

Part 3.
Though legal action was not my first choice in how to get these lies removed from my medical record nobody would force them to amend nor remove the libelous statements, so I did look into that. What I ran into was that attorneys either had conflicts-of-interest because they represented them on other issues, or that they felt this was biting off more than they could chew, as the violations span several subspecialties of law and attorneys shied away from such a case because of the lack of (or scarcity of) precedents.

I do have provable damages in that it has caused years of delay in diagnosis and thus treatment for my condition(s) and as a result I am way sicker now, it destroyed previously good doctor patient relationships within that system, the corporation sabotaged the efforts of the last two doctors there who were trying to get me independent evaluations out of state, and then after I went elsewhere it even biased my next GP and a neurologist (after both insisted on my releasing the poisoned records).

A paper trail has been sent to Secretary of Health and Human Services Sylvia Burwell, and another patient and I are now working on getting Congress to provide added protections to patients under the law via this petition;

I and others would greatly appreciate if you would share this with all who have been impacted by mistreatment in the medical system. Feel free to add your signatures, and your personal accounts where it says “reason for signing”, and be as specific as possible so that the incidence of various types of abuses can be documented and statistics compiled.

My story is the example featured in the petition. For a more detailed account you can also read the first 8 or so entries in my blog at

At Saturday, March 17, 2018 12:47:00 PM, Blogger Maurice Bernstein, M.D. said...

Giftbearer, you might be interested in joining the conversation about Patient Modesty (especially related to the way male patients are treated) which is currently going on Volume 85. The thread has been very active since it started in 2005. ..Maurice.

At Saturday, May 05, 2018 8:38:00 AM, Blogger Larrywp said...

My wife died as a result of a series of medical errors that I only discovered after she died and I began to research the disease she had through subscription based medical journals, Medical textbooks and the medical records. I have a research degree. I found and inappropriate biopsy for her suspected disease (lymphoma), a resulting misdiagnosis, wrong chemotherapy regimen; she got a Hospital-Acquired Infection (probably a UTi) from poor clinical treatment by hospital personnel, which was failed to find due to a complete absence of a urinalysis - which is on the physician. We transferred her to Duke because our oncologist recommended to us that she have a bone marrow transplant. Within an hour of arriving at Duke (by ambulance directly from the original hospital) they discovered the infection. That infection had weeks of inattention and had evolved to Sepsis. She died 6 days later. The oncologist put none of this in the record and, in fact, blatantly lied by placing a note in the Transfer Summary to Duke that we had refused a second biopsy. No second biopsy was ever suggested to us. I am convinced after nearly two years of daily research that most physicians act in this manner. Some do not. But the 80/20 rule is reversed for the Medical Profession. One cannot trust but 20 percent of physicians and hospitals and it is very difficult to know which ones they are. -- Larrywp

At Saturday, June 02, 2018 5:49:00 PM, Anonymous Anonymous said...

My mother is a psychiatrist. She did appoint herself my doctor without my consent and lied in my records to get me hospitalised repeatedly. I was shocked.

At Saturday, June 02, 2018 7:08:00 PM, Blogger Maurice Bernstein, M.D. said...

Anonymous from June 2 2018: Can you tell us a bit more about your experience? How old were you at the time? ..Maurice.

At Thursday, September 13, 2018 1:51:00 PM, Blogger Unknown said...

I live in Canada, and have been on CNESST (Workmans Compensation) for over 3 years. At the consolidation of my file before going into orientation to find new employment I had the 5th in a series of tranforaminal nerve blocks on October 19th 2017, resulting in extreme pain, urinary incontinence, radiating pain to genitals and anus,as well as to the inside of my leg and down to the foot:
February 2016 MRI shows 5 disc herniations T2/T3,T8/T9,L3/L4,L4/L5,L5/S1(expertise May 2016 Louis Besner), November 2018 MRI shows L3/L4,L4/L5,L5/S1. Progression of Bilateral Facet Joint Osteoarthritis moving up to the levels of the work injury as well as L5 nerve damage that over 3 years hasn't healed uncalculated. New injury following L5/S1 Foraminal Nerve Block uncalculated that resulted in increased pain and numbness to the left lower back/buttocks, inguinal area, and left leg/foot, severely reducing mobility. On the 19th of October 2017, moving towards consolidation and orientation, the CNESST paid for the 5th and last cortisone injection which resulted in a new injury and visible phenomena identified by multiple doctors and only partially addressed by the BEM(independent government medical evaluation bureau). During the injection; extreme pain during needle placement, painful pulse to left toes following injection continued until 45 minutes later at home the pain surpassed the numbing agent efficacity, 2 hours following injection urinary incontinence that persists more than 10 months later, by the next morning muscles in left leg not flexing, can't move toes or ankle, also trouble bending knee normally, numbness on the inside of my left leg and muscles with painful electric shocks and impulses to all areas of foot, numbness to lower back and coccyx region with radiating pain/electric impulses to; anus, left testicle, penis and surrounding area, extreme burning pain down left leg to foot during and following defecation, coldness, discoloration, inflammation especially bellow the knee, dizziness, fatigue, high blood pressure mostly unchanged since injection. I am no longer able to wear a sock or shoe because it inflames the foot,ankle,calf on my left leg.
An MRI requested weeks later by the neurosurgeon at the Jewish general Hospital in Montreal, but paid for privately by the Workmans Compensation CNESST gave a report of 3 pages in French and English in which the descriptions differed in translation and the neurosurgeon verified that there were parts of the English translation that were factual others not so, different descriptive inconsistencies were found in the French language version as well, neither of which fully corresponded to the CD of the imaging. These were then passed on to a medical expert to evaluate the permanent injury, percentage of loss, and function limitations. The doctor concluded 2% loss with only a lower back strain.
My family doctor at the Jewish general Hospital, as well as the other departments of neurosurgery and neurology have sided with me in disagreement with these conclusions. The Bureau of Medical Evaluation (BEM) used as an impartial expert gave me a 10 percent loss calculating only 1 disc herniation and without pronouncing any opinion on the new injury following the injection. A percentage of the medical opinions are based on this faulty MRI report and constitute fraud by the government agency using them to lead medical experts to opinions they support. They are under investigation by the Quebec ombudsman and are being taken before the Labor Tribunal for not following the CNESST work and compensation act. This was a government paid treatment and when we requested the fluoroscopy images from the injection my doctors were only provided a 1 page written document stating it was a successful left L5-S1 nerve block.

At Thursday, September 13, 2018 9:30:00 PM, Blogger Maurice Bernstein, M.D. said...

Joey, what you are describing is a fault or corruption in a government healthcare system. Do you think this defect is more widespread in the patient population than just affecting your injury? What is the overall solution? ..Maurice.

At Wednesday, October 03, 2018 2:13:00 AM, Anonymous Anonymous said...

Lucky you. I had this treatment for years. My mother, who happens to be an MD, had her lies/fantasies couched on my medical records. I've been screwed ever since and there is no way out of this nightmare.

At Wednesday, February 27, 2019 11:10:00 AM, Anonymous Anonymous said...

I am in the head pain of fixing lies in my medical records. Done 10 plus hours of web research already and discovered doctors lie a lot and are rarely found out.
In Florida, you can sue without a lawyer. Wining is more than merely difficult, but; Florida has a 3 strikes in court for malpractice and you practice someplace else.

In addition patients are just starting to grasp the effect of informed consent law. No consent = you can sue and it is separate from medical malpractice. Meaning small claims court. In Florida small claims costs nearly as much as filing in circuit court.
None the less every such lawsuit brings public exposure to the doctor, thereby increasing the doctors desire to do right.

Informed consent is just starting to impact the doctors.

At Saturday, March 23, 2019 1:23:00 AM, Blogger honeyb said...

I fully agree, I too have my medical records with blatant lies and doctors gaslighting in me induring the appointment and actually writing complete opposite or made up stuff that i never said about my medical history and what I was telling them the symptoms and issues I have been having going thru as far as I am concerned I never went there because it full of twisted lies. Def. Should be able to go over it with them to make sure it is TRUTH. BECAUSE I KNOW MY TRUTH I LIVED THRU THE WHOLE MEDICAL NIGHTMARE, and for them to write blatant lies and call it truth is out right evil.

At Saturday, March 23, 2019 3:05:00 PM, Anonymous Anonymous said...

JR from Patient Dignity,

It is really sad that what the community will do. I have that you are familiar with my husband's story. His medical records are full of lies. Medical records are supposed to be a legal document. However, their only purpose is to the medical community. With the use of the electronic systems, they really don't tell a whole or accurate story. My husband's sexually abusive and incompetent nurse, told downright lies 25-30 times and then omitted pertinent info like she wasn't able to hook up his IABP or temp pacer which were used to take the strain off of his heart and to monitor his heart. Not only do medical records tell lies but sometimes they tell lies from what is not in them. Omitting vital but negative information seems to be a common practice for medical providers. His medical records also state 2 minutes about his medical assault and battery procedure ended, the recording nurse couldn't remember what unconsented for procedure they had done on him. He certainly didn't know as they had committed another assault and battery on him by drugging him not once, not twice, but three times. There is no record of the sexually abusive nurse saying why she felt she needed to keep him constantly exposed for 2.5 hours. Because of one quack's diagnosis without evidence that my husband had to be diabetic, we have been harassed for months from calls about needing diabetic supplies. Reading page from page, it is clear that doctors really have not idea what they are doing as their narrative changes from page to page. One page says drugs therapy for a year, the next morning for over 12 months, and by evening it is forever as they know that stents can permanent artery damage mainly at the ends. They also know the medicines they prescribe are every bit as nasty. We live in a town where a big pharma makes drugs. They lied about him saying taking RX were okay but he has never routinely taken any rx. Just another lie in his medical record. A chaplain who invaded our privacy and announced private medical information in a public hallway 3 times lied and said we were glad and grateful he had invaded our privacy, announced private health information in the hallway 3x, and held us prisoner for over 2 hours without any word as to what was happening to my husband. As we were driving we could smell gas. My husband said there must be a gas leak somewhere. I said probably not as it was probably the day they were making blood pressure medicine. Yes, getting these records fixed are on our list but we have numerous other items too. It seems there is no shortage of how medical providers seem to enjoy inflicting pain and suffering on potential patient victims. It seems that like giving parting gifts in way of false medical records. The list of what is wrong with his medical records is endless. I could go on and on.....I do believe that intentionally falsifying medical records is a crime but you have to prove it. But they still get away with it because the law allows them to hide behind it. JR

At Sunday, April 07, 2019 1:51:00 PM, Blogger Larrywp said...

To JR, and Others Who Have Experienced Fabrications in Your's, or Someone You Love, Medical Records: I have recently published a book about Medical Errors, including my own wife's case. There was a critical lie in Her Medical Record as well as the Absence of Critical Information that Should Have Been in There.

I am putting together a Book about this Subject. If you would Be Interested in exchanging emails about Your Experience with This Problem, Please email me at: . This will only be exploratory and nothing will be reprinted or repeated without your explicit approval and prior discussion. Thank you. And my condolences to all of you who have experienced egregious abuse by the Medical Profession.

At Friday, July 03, 2020 10:12:00 PM, Blogger Unknown said...

Dear Dr. Bernstein, I am a RN who practiced for 35 years. I was valedictorian of both nursing schools I have attended. I was charge nurse of a surgical unit, Neonatal ICU nurse, 3-11 supervisor, 11-7 supervisor, unit manager, Case Manager for insurance, utilazation review supervisor, and worked on the floor taking care of patients PRN. I was never disiplined or written up in 35 years. I taught student nurses, and new nurses all my life. I did evaluations, incident reports hiring firing administrative duties my whole life. I loved my work and patients. I have been a diabetic since I was 22yrs old. It catches up to you. I take insulin. I have PBC with portal hypertensive gastropathy,esophogeal varices, portal hypertention,thrombocytopenia,sleenomegaly, a fibroid that is 13cm by 22cm, severe perhipheral neuropathy,absent reflexes,emg shows no feeling from knees Down.i was treated with morphine for year and half then heptologist suggested tramadol.I was treated for a total of four years. When the new recommendations came out regarding opoids, my doctor that treated me said his administration wanted him to stop with Rx opoids. He suggested medical mariquana but I have never used drugs like that and didnt want the sitgma attached to them. I cant take NSIDS, because of increased bleeding. I am trying to find pain relief and am actually, just starting to have notes that discount my pain, and just starting to be slanted negatively. In 35 years as a processional, and as a patient, I have seen some documentation errors but the last PCP I went to actually slanted my notes negatively with regaurd to my request for tramadol perscription, took what I said out of context and lied on the notes. One 15min conversation with him over the phone. Telehealth visit because of pandemic. He said I was pleasant and my mood was appropriate. I have decided to opt out of electronic records and care everywhere. I have also contacted an attorney who has experience with malpractice hippa, etc. He quoted and cut and paste information from a previous note, that wasnt current, and did not treat me with respect. I went to a major medical center and chose the practice from US news and world report. They gere listed and rated very highly. I have never seen in 35 years of practice a doctor that lied outright in notes, took what was said out of context, made things up. I have a chart 1500 pages largue, and nothing else negative in my chart. I am very upset that He did this. I am going to fight with the help of an attorney to have my note amended. I can just imagine what will happen down the road further negative notes then it will be drug seeking behavior!! It has never happened in 35 years that I have been reviewing notes, or my own patient progress notes. Also pain management wants to do epis and injections and my pain is soft tissue, they dont always perscribe narcotic pain relief. I was only using 50mg tramadol, maybe 3-4 times per week when tylenol or cbd oil was not enough. I read the recommendations and i qualify under comfort care. Any ideas that may help? Thank you

At Saturday, July 04, 2020 9:07:00 AM, Blogger Maurice Bernstein, M.D. said...

"Unknown" from yesterday": I can understand your frustration, anger and regarding your current medical management and concern with regard to what has been written about you and your case. You truly have, based on what you wrote, a complex medical state and medical history.

Looking back at your own extensive medical professional work history, have you ever seen professional misbehavior in one form or another which approaches that of what you have been personally experiencing?

Many folks writing here have always been in a category of a patient and not a healthcare provider. You have much to contribute to what you have witnessed with regard to change in provider behavior over the years.

For continuity, perhaps you can provide us with a unique pseudonym rather than the non-specific program generated "Unknown". I am looking forward toward your response to my request regarding your insight. ..Maurice.

At Friday, September 04, 2020 1:19:00 AM, Blogger Quickdraw2016 said...

If you have any doubt about how often doctors, nurses, etc falsify medical records just take a hospital bill into the admin office after you've been released and ask them to go over every line of of the bill and explain what the charge is for, why was it medically necessary, who athorized it, and what exactly was it needed for. When I did this after I was admitted to ER when my doctor got my results back on an A1C test. I found over $10K in charges for labs that were not needed( A1C was done every day but the test gives a 30 day average of glucose levels so it serves no purpose beyond 1-29 days, treatments that were not given(smoking sessastion) drugs I was charged for that I did not take, I thought it would never end. Saved my insurance $10K but not a dime for me.

At Saturday, September 05, 2020 8:34:00 AM, Blogger Maurice Bernstein, M.D. said...

Quickdraw 2016, sad story you present regarding medical administrative function but thanks for ventilating. By the way, the A1C test actually reflects the blood sugar levels over a 3 (not just 1) month period and would require retesting immediately only once after the first results are back if those first results were inconsistent with the patient's diabetic history. ..Maurice.


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