THR Doctor notes

Jason11

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Thanks to anyone that can or does answer this question. So i saw two doctors, and when reviewing their doctor notes, I saw the first doctor had in her notes that she told me things that she never told me. she was a dermatologist and said in her doctor notes that she told me about sun screen and ABCDE's of melanoma,....... she never told me anything about this when I saw her,

The other doctor is an Orthopedic hip surgeon, he ( or his staff ) did not write all of my medical problems in his doctor notes. I know I told them and also put in the intake questionnaire doctors have you fill out . I know because I made a copy of the intake questionnaire. They left out I get boils, and I have some nerve issues. My question is, is this normal , for them to leave out information, or add information they never tell you. Thanks

one other thing the Orthopedic office left out of the doctor notes (my parents medical history ). They just wrote "none". when in fact I did write on the patient patient intake form, my dad had Parkinson's and my mother had Alzheimer's.
 
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subie2021

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It's normal for my providers. Every single time I see my PCP, the notes mention 'patient education' concerning diet and exercise and we've never ever discussed it.
And both PCP and OS have left things out of visit reports. Mostly it's stuff that isn't pertinent to the visit. If it's something I think is relevant or important to me, I bring it up and press the issue, and get some answers. Those topics then get mentioned in the report.
My providers have access to each others' notes, do yours? So possibly a doc has read and is aware of certain issues, but doesn't think it warrants attention.
If you're worried about something, like maybe your boils, bring it up and discuss with your surgeon so you're sure he/she is aware, and you're reassured that they know about it.
 
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Jason11

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Thank you for your reply Subie, I did talk to the surgeon at length about the boils, and talked to a dermatologist about them as it relates to hip surgery, both doctors gave me the ok for surgery. I do thank you for your reply, it helps.

As far as providers having access to each others reports, I think even if they did, they would not read them.
 

Eman85

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As far as the boils go I had problems with them and made my OS aware and he saw no problem.
As far as the health care system and Dr.'s making fake reports about what they discussed it seems to be the norm. I recently went to a Podiatrist and the report of my visit wasn't anything like I experienced and I was there. They are playing the CYA game.
 
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Jason11

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Thank you too Eman, for your reply.
 

Zoebichon

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Sometimes I think they copy and paste the same generic statements for each patient!

At my 2 week post THR checkup, the PA stated that I had no numbness in my thighs, which was not true. Nor did she ask about numbness.

She also stated I could do straight leg lifts when again, she never asked me to demonstrate it. Also, my discharge papers said NO straight leg lift until at least after my 6 week checkup.
 

spaniel

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Yes-all the time, and not about minor issues. I have reached out to regulating bodies about this very issue. Minor things don’t bother me in the least, but issues pertaining to actual data-that’s another matter. Examples: issues related to adverse reaction or inappropriate rendering of anesthesia.
 

danelady

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When I started driving a truck I was told right away that should I get in an accident with an animal....like with a deer, NEVER write in the accident report 'I hit the deer', say 'the DEER HIT ME'. It's all about who to lay the blame on. Write perfect notes and deflect the blame off of you
Medical Board: Dr So&so, did you explain all the risks that come with this operation with your patient?
Dr So&so: Yes I did, we discussed them in detail. The 'in detail' that was added to a lot of his answers confused me. The only detail I remembered was his seeing his back as he took his exit out of room.

The one that really angered me was where after our visit he wrote 'all and all her pain has subsided'. My pain has NEVER subsided. Sometimes the pain sucks the air out of my lungs and whimper escapes. As much as I try to hide it, people turn to see where that sound came from. The pain has definitely not subsided, but it takes a lot of the pressure off of him, I guess.








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Pumpkin

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I've run into the same thing with my notes, if there is a serious omission or error be sure to bring it to their attention.
 

Layla

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Too bad we can't sign off on these records as soon as they're recorded. Most have no idea what's documented their file until they get into a bad situation and request copies of their medical records.
 

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