medical records

I was born before the laws changed so I have no medical records before my K pouch (even then...) but Dr C gave me a full copy before I left the country and all opperative reports since...here in France it is iffy...they can write just about anything they want on your files...I have had reports refer to my colon as being intact (!!?) and healthy as observed during surgery, having an end ileo (that might be why I woke up with a Flang/bag attached to my stoma!) and every other possible mix up...so I would take it all with a grain of salt.
I would keep my own records, ask for photocoies the 'day of' and keep all xrays and lab results.
Here the patient leaves the hospital with all xrays and results so we are considered responsible to stock and store them. Not sure if they do that back home.
Keep very close records of everything done to you and add to your own personal files.
Sharon

Part of my job involves the collecting of medical records of others pursuant to HIPAA authorizations furnished (I am a personal injury attorney). Depending on which medical provider you are dealing with it can be frustrating. I recently took the deposition of someone, learned about treatment with about 5 medical providers I didn't know about, had him sign an authorization which his attorney approved, and sent it out and got all missing records within two weeks. It's not always that easy, though.

I save all my diagnostic testing records and ESPECIALLY the color photos of all of my annual scopes. I guessed a long time ago that keeping the color pics of the scopes, one hard copy, would be very important in case I ever switched Doctors. I did switch Doctors a few years ago due to an insurance change, and it was critical that I had pics of the scopes taken in the prior years.

I recently had to go down to Yale New Haven Hospital, St. Raphael Campus to get a CT Enterography film of my ileum taken in 2008. I called ahead to the radiology department and told them I was coming in to pick it up and to have it ready. I then went in and although they were fairly busy, waited only about 20 minutes, signed their forms, produced my ID, and they had a burned CD waiting for me. It was really pretty easy.

Regarding paper records, if they are voluminous, most hospitals will put them on a CD for you. If it is over 100 pages I would ask them to do that.

Always go right to the records department of whatever office you are dealing with so you do not waste time, get the names of people you are dealing with and tell them exactly what you are looking for. Ask how and when you can follow up.

Once all records are collected organize them by year. I have my records organized by year going back to the 1990s.

CT the one thing I have kept is my scope reports. But the challenge now is I have to collect from multiple providers in multitudes of specialities.. so many due to insurance changes at one time which required me changed providers and also having to seek higher quality providers in many instances. In addition, getting ER, surgery and operating info seems particularly challenging. Don't understand why.Getting scans on a CD seems to be the easiest thing to acquire. Maybe a physical trip to the medical records office as you suggest might help.

Trying to organize this by year doesn't seem to make sense to me, since the issues are cross-functional.. ie. arthritis, GI. Guess I just have to start putting some system together and can always change it. So far I've probably collected 300+ papers.. not counting what I already had with scans on CD and scope reports.

Also how do you recommend keeping up to date on it. My docs surely don't have a report written when I leave their office. Sometimes they give me a summary of the visit, but it is not detailed. The detail is generally dictated and written later, sometimes even 3months later. Sometimes they forward that to my PCP. Oftentimes they don't. So how do you recommend staying on top of this? In the last 2months alone I have probably had 12 doc visits, 2 surgeries, 2 CT scans, 1 xray, 1 scope, 2 hospital based infusions, and probably more stuff that I have forgot about!!!
any ideas would be greatly appreciated.

I always ask my GI or other specialist to copy both my PCP and me on his report. Then I follow up if I do not get the report in say 2 months or so (most of them send their dictation out so it does take time).

My current GI actually communicates by email with me and he has sent me reports and scope pics by email. Most of the younger generation Doctors are computer savvy and do this. If they do then you can also send email reminders, either to them or their assistant.

I prefer organizing by year rather than by specialist but there are many ways you can do it. It depends on the amount of records as well. I can see that if you have many specialists you can organize it by specialist. But within that folder I would also organize chronologically by year.

Regarding the surgeries, speak to the records department of the hospital, see if they will put all the records on a CD and arrange to pick it up. Not sure it will be as simple as that but for my procedures it was.

I frequently seek medical records reviews from doctors. When I do this I organize chronologically by event. For example if there are 3 motor vehicle accidents involving the same injuries or same body parts that happened in 2003, 2005, and 2007, I will organize chronologically by each accident and then chronologically starting with the 1st treatment for each accident.

Doctors have sometimes asked me to do this before I send them the records but now I do it as a matter of course.

Good luck with it!

I am not sure what the best approach is. I would not ask for complete medical records, as there would be too much. I think that operative reports, imaging reports, and consultation reports would be most useful.

I haven't had a problem, since I have been with Kaiser since I was 10 (1965), so all my records are centralized. Plus, they have been using all digital records for over 10 years, so any doctor in the system can access it all. Most doctors and hospitals will archive paper records after about 10 years or so, so getting those records are a pain, because they are either in boxes in warehouses like on "Raiders of the Lost Ark," or on microfilm.

So, if you can't have the reports, if you at least keep a running diary of procedures, diagnoses, etc., THAT would be helpful. Most doctors don't actually read all the records that are sent to them, but just go for the most recent or relevant reports. Then they hope you give them a good history to fill in the gaps.

Jan

Jan,

Your post reminds me of a case I had a few years ago in which there were voluminous medical records received in discovery. Typically we send all the medical records we get in discovery to the insurance adjustor as attachments to an email. So we did that in this case, and I had my paralegal send up all the records, hundreds and hundreds of pages of them.

So the adjuster calls me up. He is one of those senior savvy types, has worked for the insurance company many many years and likes to see the forest rather than the trees if you know what I mean. And he says to me, "can you do me a favor? I mean I really don't want to look at all of this crap. Can you cull out for me the original ER report, the treating orthopedic surgeon's reports including any disability ratings he awarded, the MRI reports, and the operative report? Because I don't really want to look at all this other junk. I don't need the PT records, the acupuncture records, the chiropactor's soap notes. Just send me the meat and potatoes of it. I really don't want to see anything else. And if you can do it today, that would be great."

So I culled out all the "meat and potatoes" for him. Took me about an hour but I made him happy. And it is my job to keep them happy.

Well I got a good start on it yesterday and have a framework of a filing system in place! Its overwhelming. My problem is not just that I have had to see so many specialists, but that many of my doctors quit practice, retired, or moved out of state. Also, I had a major insurance change at one point in time, so my providers at that time all had to change. Since being diaganosed with UC 10+ years ago - I have had 6 GI doctors and 3 colorectal surgeons. crazy. So now I have doctors in various specialities in three different medical systems. CC - which is all electronic like kaiser, a local one - which is recently electronic, and another local one - which doesn't even know how to spell the word "electronic". And no one in any of these 3 "systems" can share information with the someone in the other system. And then if you ask someone from one system to send the info to someone from the other system, there is no guarantee that is ever done.

ANd yes, those were the boxes I had been checking on the relase forms: operative, imaging, and consultative... (my PCP had clued me in on that!).

I like the idea of a running diary. Should've been doing that for 10years. But I'm going to see what I can resurrect. And then use it from here on forward.
thanks so much.. I feel a huge relief just getting the beginnings of it organized.

My internist recently chose to be a concierge doctor and I chose not to give him $2,000 a year above and beyond insurance in order to keep him as my primary care provider. I miss him terribly but even though he is the very best, the hospitals out of which he practices aren't. When I left, I asked for copies of all the medical records he kept on me. He didn't put them on a CD but instead copied all of them. He charged me per page and it came to about $30.00. I hand carried them to my new internist who did copy them to an electronic file they keep on each patient. Then, they gave me the paper copies I had brought to them. Easy solution for me....except giving up a doctor I truly trusted. Wish he practiced out of the hospitals I prefer.

Trying to get all mine together as well - finally found a GI who might take me on. The Physician's Assistant up in Cleveland recommended organizing by lab work, pouchoscopies, scans and such, pathology reports, etc. Haven't gotten that far yet, but it's an incredible undertaking.

My records from the 5 years of my illness total over 900 pages and yes, I have all of them in a fireproof box in my house. Jan I respectfully disagree about just culling out operative reports and such as I have caught many mistakes in my office visit reports and other such routine documents including: wrong medications, treatments that never happened, treatments that were completely left out (for example, my original surgeon's office had no record of my being treated for apthoid ulcers post surgery 3, no record of the medication they prescribed, which I ended up being allergic to, and subsequently no record of the allergy). I wrote a letter to the surgeons office noting the missing information and completing the record. I also filed a complaint with the hospital, even though I no longer use that hospital for GI needs.

It can be time consuming and it can cost money, at least when I had my files done. I was lucky to have all of my records in just two facilities. I purposely keep as many of my providers in the same hospital system as I can, but I"m lucky to live in Boston where most hospitals can handle any issue so you can pick one and pretty much get treated for anything that comes up.

My point was not that all those records were of no interest or value, but that I can assure you that doctors will not read all of that. Their time is limited, so they just need the highlights. Yes, there are errors, so it is even more important to keep tract of your history to relate to your current providers. In the long run, many of the details really do not matter.

Jan

jill.. I too have just found that a lot of my paperwork has mistakes, wrong medicines, treatments that were left out. And best of all.. some of the screw ups that the doctors did have definitely been omitted. But most recent was just last week after and EUA surgery, I had some kind of massive allergic reaction to one of the drugs they administered while I was under. When I woke in recovery, the anesthelogist himself was sitting there watching me while pumping the iv full of more bendrayl. As I was quite outof it, all I remember him sawying was it was either CIPRO or one of the muscle relaxants. And in the outpatient post op area, the nurse said she couldn't find the info on the computer. And there is no mention of what drug it was in any of my paperwork they sent home with me.

Do you think it is important to always get that paperwork straightened out?

To me it is. What if you are unable to respond in the future and they are trying to figure out what medications give you? If the record isn't right you could end up with another allergic reaction...since this is something avoidable if the paperwork is right, to me it's worth checking that the record accurately reflects what happened.

I am not sure it is worth it trying to get the record altered, but it is definitely important that your chart is flagged for the allergy. You will need to question the surgeon or anesthesiologist about it, and since they were not sure which drug caused it, you will need to list all of them. When your chart is flagged, they do not go through your records to read about the incident, it is just one of those up front warnings that everyone can see right away. The type of reaction is important too.

The reason is, they don't need all those details, just the important facts. Having worked in hospitals, I know that is how it works. They flag your wristband that you have allergies, your chart, and on the leading page on the electronic record. Nobody has time to flip through reams of pages. Allergies are on the top of the priority list, along with things like diabetes, pacemaker, etc.

I don't know if that is the best way or not, but it is realistic.

Jan

It can be dangerous to ask a Doctor to alter or redact or modify medical records, and I have seen it blow up where there was a related legal case. What usually happens is the Doctor is asked to make a change and he/she does not go back and read the prior records carefully, a change is then made which either makes no sense, does not fit in the chain of records, or else blatantly contradicts something already written. When this happens Doctors can easily be reduced to an incredible pile of smoldering rubble in an expert witness deposition.

Of course, if there is no legal case and nobody is ever going to look at it except you, it's just harmless stupidity as opposed to stupidity that is broadcasted across your local courtroom with your name attached to it.

Doctors will also cover themselves when things are not reported to them and shift blame to the patient. I saw a case blow up earlier this year when an expert neurosurgeon was confronted with records his patient had never shared with him documenting reported cognitive difficulties and diagnosed cognitive impairments as a result of brain surgery many years earlier. The expert neurosurgeon quickly withdrew all his opinions of causation then and there, and the case ended very quickly then and there. A lot of doctors, if they get put in a situation like this where they have a choice of maintaining their professional reputation or killing the patient's stupid case, will choose the former.

Oh no, you NEVER actually alter a record that is in place!!! I've seen it done in lawsuits before also, and it is a big mistake. Once there is litigation in process, you never go back and change things.

However, you can make corrections to the chart. The correct way to do it is to make an addendum that is dated after the fact. Basically, you are just creating a new note stating you are correcting something that was charted in error or omitted in error. I have seen that, and I have even done that, and that is not a questionable act.

For example: after a very hectic night where I spent the entire night at the bedside with no time to do any charting, I have gone back to write incident reports and progress notes after other people have done their charting. Sometimes, it just happens that way. Or sometimes doctors will write an addendum after they get additional information. It is proper, as long as you do not try to back date things or try to erase a record that exists.

Jan