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JLeslie's avatar

Have you ever looked through your medical chart and been shocked at something that was written on it?

Asked by JLeslie (54434points) August 30th, 2014

A diagnosis.

A lab test or lab result you were never made aware of.

Something you said or described that was misinterpreted.

A comment about you that you find offensive or inaccurate.

Also, you can include a diagnosis that later was disproven by a different doctor, but it remains wrong in the first doctors chart.

If yes to any of these or anything else, and you feel inclined to share, I would like to hear the stories.

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19 Answers

janbb's avatar

Can’t say that I have. I’ve never really had the occasion to look at my medical chart but I feel – and hope I’m right – that my doctors are honest with me and that we communicate well.

Thinking about it, I did have a misdiagnosed eye problem for five years that said that my corneas were deteriorating. This was upsetting until a later eye doctor rediagnosed the problem but I could understand where the misdiagnosis came from.

hearkat's avatar

I was in Pre-Op for my hysterectomy and the nurse left the chart next to me so I was going through it, and saw a notation on the EKG about an abnormality! Hello – you’re about to put me under General Anesthesia, and I had an abnormal EKG!?! The anesthesiologist came down and said that while the pattern was atypical, it was not unusual or unsafe. I was appeased, and all went perfectly normally for the surgery.

There was a recent NPR Story on a trend for patients to review the physician notes. Personally, I think it’s a good idea, because with EMR, there are often typos. Sometimes the notes are partially entered by the assistant and partially by the doctor, which can result in discrepancies.

syz's avatar

I had a mis-key in my history follow me for years that I couldn’t get corrected.

SecondHandStoke's avatar

Don’t panic if you see SOB on a chart.

It doesn’t mean you are a complete bastard.

It stands for Shortness Of Breath.

kevbo's avatar

My latest doc, who either left or was let go, asked me if I get the flu shot. I said I had in the past, but hadn’t in recent years.

When my labs, etc, came back, it said I had “refused.” The a-hole never offered!

CWOTUS's avatar

Wellll… I was “fired” by my last doctor.

Out of the blue, and for no reason that I’m aware of. I received a letter in regular mail (in a hand-written envelope), which was a copy of a mail sent (apparently) by “registered mail” six months earlier… to my name, but at a completely different address, and one where I have never lived or even visited. The letter copy in the hand-written envelope had been laser-printed (that is, from a computer), and contained the incorrect address that would have been used for the first letter. (Obviously, I had never seen the letter that was addressed “to me” six months earlier.) The letter had some kind of boilerplate that amounted to “difference of opinion”, which is utter nonsense, because we never had any discussion to amount to a difference of opinion. So it’s either a made-up “reason” ... or sent to the wrong person.

I thought about that for awhile.

I came to the conclusion that if the doctor had such a serious problem with me that she felt she could no longer see me (and I had only seen her once or twice, anyway, after my prior physician moved to a different part of the country a year or so earlier), and that she couldn’t just talk to me first, to at least let me know what was wrong or what she had in mind, then that was a “professional relationship” that I didn’t want in any case. So if the doctor was right in addressing me with the discharge, and had reasons for not wanting to handle my care, then I would accept that without further discussion.

Second, if the intent to discharge from care was really meant for someone else, who actually resided at the address where the letter was first addressed, but it was sent “to me” (twice, and with a six-month gap between failed the failed delivery and the actual one – and the follow-up was so shoddy), then their office is screwed up beyond my comprehension and acceptance (in addition to sending a letter with no monetary value by “registered mail” – which is ridiculous and unnecessary). They cannot be trusted to do normal business correctly. In that case, I will have been saved from future, possibly serious mistakes by this administrative mistake, and I accept the discharge.

So it hardly matters what is on the chart; it’s very likely to be an error, or even someone else’s information. And since my health is generally good, and there are no chronic conditions for which I need a continuing medical history, I’ll start fresh with my next doctor and not even request the file to be forwarded. So it’s all good… except now I haven’t had a physician for about a year, and it’s hard to find one in this town who is accepting new patients. And I absolutely will not attempt to return to the practice that “fired” me – which is the largest and most convenient one in town, dammit.

Pachy's avatar

No, but I recently unknowingly had another patient’s worrisome lab results read to me on the phone by a nurse. I spent several very nervous days until my doctor met with me and discovered the error.

snowberry's avatar

I read in a doctor’s notes that I was “rather plain”. Now why bother to put that in a doctor’s notes, and what in the world did that mean? Why would a doctor care whether their patient is wearing makeup or not? What would they have said if I had showed up wearing makeup and a suit and heels?

If someone knows, please enlighten me.

Now, if I have a doctor who is judgmental like that I find another doctor.

SadieMartinPaul's avatar

Yes! When I was a late teenager, I went to my dentist for routine treatment and had a quick glance at my file. Several visits earlier, the hygienist had written that I’d had CANCER (yes, all in caps), and that I was VERY worried and concerned. I’ve never had cancer, and I wasn’t the least bit worried about anything. Apparently, the hygienist had either confused me with someone else or written the note in the wrong patient file. I told the dentist to scratch-out the inaccurate words immediately, while I watched him do so.

My mother-in-law once peeked at her file – her physician had briefly left the examining room – and read, “The patient is morbidly obese.” The words were 100% accurate, but they deeply disturbed MIL. Facing the reality hit her like a hard slap. Denial is easier. Once, she was making fun of another woman for being very fat, and she said, “She’s at least twice my size!” The truth was, the two women looked pretty much the same.

Inspired_2write's avatar

yes and I was surprised to find that my “lower back pain” had been merely written off as trival when infact through a Scan it was determined years later that my disk in the verebra was damaged significantly to cause the pain that stayed with me for years!
( squashed disk) . fortunately it did not hit a nerve which would be intolerable to bear for anyone.
taught me a lesson in that maybe we should request copies of our own medical files.
As it runed out a “phyiotherapist” looked up with my permission my med files and located that
diagnosis. It explained everything as to how come my back was painfull for so long.

majorrich's avatar

When my father was still alive, it wasn’t uncommon to have information from his files put in mine. (So sometimes I was in my 40’s and sometimes in my 80’s) The hospital had installed a computerized system that allowed clerical people to make errors at astonishing speed!

JLeslie's avatar

I have seen notes in charts that are completely innaccurate regarding what I have said about my symptoms or condition.

A girlfriend of mine was misdiagnosed for several years and it caused her health insurance to be extremely high. The diagosis was pan ulcerative colitis if I remember correctly, which has an almost 100% chance of eventually getting cancer. She also went through a colonoscopy once a year for several years, and lived with pain and discomfort, and had ithe diagnosis hanging over her head. Eventually, she changed her diet and everything got better. She no longer felt bad and her colonscopy was now nornal. But, her insurance still counted the old diagnosis. I don’t know if now years later that has changed. I guess with Obama it would matter less anyway.

I had another girlfriend that found out she had an abnormal PAP smear looking through her chart and she had never been told.

@snowberry They look at what you wear as an indicator of your state of mental health and other things. Working in the medical field has made my sister a little compulsive about what she wears, her nails, and even how extremely tidy she now is at home. She doesn’t want to be seen as off balance by her friends. In the charts they usually state your disposition too. Pleasant female, agitated female, visibly upset, that sort of thing. It’s a nightmare, I don’t know which state of being they take you more seriously when you have a complaint about your body being sick or in pain.

Myuzikalsoul's avatar

I was once misdiagnosed as having Scabies when it was actually a MRSA infection!!!! The MRSA is bad enough, but I hope they took the Scabies off because that is just embarrassing!!!!

snowberry's avatar

@JLeslie That’s kind of presumptuous though. Nobody told me I had to “dress up” for a physical. I don’t wear make up because I don’t like it. I hate the smell of it, I hate the feel of it on my face, it’s quite expensive, and it’s really hard to find non-toxic makeup. What I wear has nothing to do with the state of my mental health (which is quite resilient, calm, and happy). However when I was quite ill once I showed up at a doctor’s office in my bathrobe with unwashed hair (Gracious! The woman must be a mental case!).

I have NO patience for idiots (doctors) like that.

JLeslie's avatar

@snowberry Make-up probably doesn’t matter as long as all other grooming is good. Although, I put on make-up for “well” visits that I will still have some questions to ask. There have been studies that patients are treated differently depending on how they outwardly present themselves, aside from marking charts. I put on make-up and try to look good for any interaction that might be a little difficult. Returning something to a store, doctor, asking for help from someone I don’t know well, going through immigration and customs, just going through security at the airport, meeting new people, and on and on.

Otherwise, just doing my nornal errands around town I don’t care if I have make-up on, my hair is often just back in a ponytail. At the supermarket you will find me in work out clothes half the time.

Edit: I just did some googling and quite a bit shows up about how much difference make-up can make at work. One article talked about how we dress indicates to some people how much we care or respect the person we are meeting with. All sorts of judgements about how competent we are, how seriously we take what we are doing, and so on.

snowberry's avatar

@JLeslie When I showed up for that doctor’s appointment I had taken care to wash, I combed my hair and wore decent clothes. Apparently I needed an appointment at the hairdresser and buy and wear a bunch of makeup I don’t like and never use to get a decent physical. And it was a woman doctor to boot! I’m glad I fired the idiot.

JLeslie's avatar

@snowberry I don’t have the answers. If I look too good I worry they don’t take my pain seriously.

JLeslie's avatar

Also, I don’t see much difference between men and women doctors. As I get older I like having women doctors more, but one of favorite GYN’s is a man. When I had a cancer scare it was a man and I was very happy with how he treated me. Doctors, espeically young doctors I think are in very good health with lots of stamina, how else could they get through the rigors of med school, internship, and residency, and so don’t really “get” chronic illness I don’t think. Since they are doctor’s they get treated differently by other doctors. Many of them have a parent who was a doctor, and never were at the mercy of the medical system in the same way we nonmedical people are.

kruger_d's avatar

A psychiatric unit once called to confirm an appointment I never made. Took some time to convince them that it was another patient with the same name. I had only been there once for allergies.

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