Error in medical records - question

[flutterbee]

My GP gave me a copy of the report the rheumy sent to her so I can take it with me to the rheumy I'm going to see for a second opinion. Upon reading the report, I noticed a couple of errors in the paragraph describing my present history. It's not diagnostic errors, just errors with what I presented with.

For example, it says that I have had back pain in the upper back and chest for years. That's not true. It's been my lower back just above the tailbone and the sacroiliac area. And it's been since childhood. The upper back pain is much newer starting within the last 4 years and has become markedly worse in the last 6 months.

That may not seem like a big deal, but if I end up having to apply for disability (I hope not), I don't want it to look like I'm changing my history around, Know what I mean?? Plus, diagnostically it may end up being very significant. I probably will not see this rheumy again (especially because this report states flat out no fibromyalgia tender points, but that's exactly what he diagnosis'd me with 2 weeks ago).

So, I'm thinking of sending a letter highlighting the discrepancies - just to have it documented. First of all, is that a good idea? Secondly, does anyone know how I can make sure that gets into my medical file and gets sent along with any documentation that might be requested by anyone - whether it's another doctor or disability people (heaven forbid)?

by the way, not only is my sed rate elevated, but so is my CRP (C-Reactive protein) which is another indication of inflammation. Yet he says I don't have any inflammation.

 

[gcvmom]

I think it's a solid idea to correct the errors. Some day those details may be important, like you said.

I guess you would want to follow up with the office that generated the report and ask them how long it would take to make the corrections, then add a week and call to find out if the changes had been made and if you could get a copy of the corrected report. If they balk, you can say that you need the information to take with you to another consult and it's important they get the right info.

You're right on about the SED rate and CRP -- you've got inflammation, baby, but maybe it's not where he was looking? Unfortunately, the markers don't tell you where the problem is, just that it's there. They'll have to start assessing other signs and symptoms to narrow it down. Hope you get some answers soon.

 

[Hound dog]

Get those errors corrected. Then check to make sure they did it.

I'm glad you're getting a second opinion.

((hugs))

 

[Lothlorien]

Yes, write the letter and send it certified. Then follow up with the medical secretary in two weeks to make sure that it is actually in your file and not sitting in with the papers to file.

Unfortunately, there are many, many doctors who either don't dictate a correct history and/or they rely on a "form" that gets filled out by the transcriptionist and if it's not detailed by the doctor, it's all automatically filled out in a format, which is generally all negative for any abnormalities. I see it all too often.

When you bring the report in to see the new doctor, bring the copy of your certified letter, as well.

It's always a good idea to get copies of any reports, especially when going to any specialist. You were smart to get that.

 

[AmyH]

I agree with Lothlorien, send it certified, follow up and keep the return reciept. With the new laws if they don't keep it and you have proof that you sent it they have a big problem on their hands.