Are you checking your "chief complaint" at your docs offices?

Discussion in 'Fibromyalgia Main Forum' started by 2sic2mooov, Nov 18, 2008.

  1. 2sic2mooov

    2sic2mooov New Member

    I am not one to look over my med charts or ask for copies. We are on a system where we can look up records online, at least for some visits. I was shocked and very upset when looking back at some lately online and found that the docs---well, actually the med techs or nurses had written in their VERSION of my problem (chief complaint) on my chart. Last week I went in to doc after having numbness in extremities on one side, "gurgling sounds" in ear on that side, headache, heart jumps, and deep leg pain. also REALLY confused and brain function almost comes to a halt. This lasted about 30 seconds to 2 minutes and a nurse on phone told me to come in just in case it was a 'TIA'. (this happened 4 times so far).

    Went in, the PA sent me home with the whole "not to worry" thing. I found yesterday when looking over old test results, that my explanation of what was going on at the appointment last week was simply written on my chart as "leg pain" .
    WHAT!!!! I live with pain everyday and extremely rarely go in for pain management. I couldn't believe that after 2 nurses had to prod me to get in to doc and not let these symptoms slide, I find that the docs hadnt even documented what really was going on! From now on I will stand right there and look on the computer screen to see what they are writing down and make myself very clear. I can see now how things get missed or "hidden" at the docs offices.

    My brother was found to have luekemia after complaining for over 2 years at his exams that he had inflamed and painful lymph nodes. docs attributed to a cold or virus. He continued to explain and show them the nodules. Not until he had one become very enlarged in groin area and my brothers' wife DEMANDED them to test it, was it found that he had leukemia. When going back to all of his charts, he found absolutely NO documentation of his complaints about the sore inflamed nodes, along with other symptoms including dizziness and fatigue. (Symtoms that were WAY strange for him, considering he was healthy as a horse most of his life).

    It is very important for us to make sure everything is getting into our records correctly, not just for legal issues, but if docs need to go back and look at our case, or maybe a second opinion is requested, you want them to see the whole picture. No wonder we get the rolled eyes and such when we come in "AGAIN". They write down the same thing every time....pain, chronic fatigue, etc. and dont categorize it or explain it. They could be missing important pieces of the puzzle that is our disease. And sometimes a different tx plan would be given if they LISTEN to us and LIST what our problems and concerns are.
  2. daylight

    daylight New Member

    This is so very important that patients keep track of what is
    been written in their chart. Doctors and nurses do make mistakes at times. Nobody's perfect. Plus some "medical staff"
    can be down right mean to people with "invisible illnesses".
    My grandmother was ignored and overlooked for years . They
    finally took her seriously when they found breast cancer. They told her that they had removed it all and sent her on her way .
    She only had a couple of followups and they stopped listening to her complains. She was having trouble swallowing for a year. But the doctors just told her to lose weight and that it was stress. After a year my Aunt finally got her to make the doctors listen but it was to late. They found stage 4 throat cancer and it had spread through her lymp. system.
    All she got was chemo. and a few weeks in the hospital. When the let her go home they said she'd be ok but she died at home the next day. In front of my Aunts.
    So my point is ...Don't give up,keep on top of your records,
    fired uncaring doctors, do all that you can to stay as healthy as possible. Never give in ,Never surrender. Ok may I didn't just say that .lol ;)
  3. tansy

    tansy New Member

    I requested copies of my hospital records. Neither I, nor my PT, could get the info we needed; now I know why - my difficulties and post operative complications were not recorded; we think this is because they were not aware I had been warned about the possibility of nerve damage etc. In requesting these records I discovered my brief computer based history where much has been left out including the most important info so now I will have to ask my GP to have them corrected.

    A few years ago I obtained copies of my primary care records and that made me realise how important it is to ensure what we report is recorded; likewise test results and other Dx.

    My surgeon asked why my referral to him was so late since the delay adversely affected my prognosis; getting copies of my medical records highlighted when and how this happened.

    tc, Tansy
    [This Message was Edited on 11/19/2008]
  4. gapsych

    gapsych New Member

    Mustluvdogs, a very good reminder.

    Someone told me about this when I first was filling out my disability papers and I feel it saved me a lot of stress. I have now been on disability four years. I have private disability through my states teacher retirement system.

    Once a year, I have to provide two doctor's opinions that I am disabled.

    When it is getting to be that time for the doctor to fill out the papers, which are much shorter than SSDI or SDI, I make an appointment with the doctor and ask her if everything is documented in my files and we go through them together.

    This is even more important as my HMO now has a department that fills out your disability forms. This gives the doctor's more free time but at the expense of someone trying to figure out the doctor's notes.

    Thanks for the reminder and a bump.

    ETA 2sic2mooov, You post was very informative. Thanks.

    [This Message was Edited on 11/20/2008]

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