improper and incorrect medical records that might bite you

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Brad W

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I was just reviewing some clinic notes that were posted after a consult meeting with a surgeon about potential procedures for GERD
It's a doc attached to a major hospital chain in the area, the same that all of my general family docs have been for a couple decades at least....so they are tapped into all my medical records.

I'm not surprised about it.... I've seen this sort of stuff before...but I am a little shocked at the sloppiness of it all...and I'm left thinking about teh potential gottchas with the FAA since this stuff is written in "ink"

Basically it seems like the docs and technicians are just sloppy with notes and codes, and write down things that are simply just wrong.

Some examples
in my listed current meds, is some obscure low dose anti inflammatory drug that was prescribed temporarily several years ago for an acute condition that I had....long ago resolved, it was never a refillable prescription, and clearly they know it.

They show that I have "Mild Intermittent Asthma". Long ago I was diagnosed with reactive airway disease and in that process was thoroughly tested by pulmonologist and they explicitly ruled out asthma. I absolutely do not have asthma and they know it. In fact recently we have figured out that the reason or trigger for the cough has been the GERD all along.​

I'm left with such disappointment with the sloppiness of it all.....
 
Brad W said:
in my listed current meds, is some obscure low dose anti inflammatory drug that was prescribed temporarily several years ago for an acute condition that I had....long ago resolved, it was never a refillable prescription, and clearly they know it.
Click to expand...
Once on the list, they stay on the list until someone removes it (at least in my experience). In my case, the someone was me.
 
FAA medical - Even after an exam by an AME your records are reviewed in a cubicle in OKC where every incorrect entry is considered accurate.

Basic Med - your physician is well aware of the fallacies of medical records and can adjust accordingly and decide whether you can operate safely from the medical perspective. There's a good reason that more than 60,000 pilots are using it.
 
Once I got a report from a medical facility after a work up for a benign condition outlining my heart attack.
I didn’t have no damn heart attack and wasn’t even there for my heart!
I could tell from some discrepancies (date of birth) that they mixed my records up with some other dude and I Was Pzzzed!
I called, and wrote a certified letter asking for the records to be corrected and re-sent. They did so with a letter of explanation & apology.
That could have been a horrible event If the medical branch ever got ahold of those erroneous records.
 
In the old days before computerized medical records, patient histories typically were concise and limited to current and or relevant information. The 2009 HITECH act mandated a switch to electronic medical records or EMR's. EMR's bring both good and bad. Access to data is great. However, now when I read a H&P (history and physical) it is multiple pages long and filled with everything a patient may have had including (sometimes) erroneous information. Once it gets into the record, it seems to take on a self perpetuating life of its own; it will automatically import into new records. Much akin to errors on a credit report that may be difficult to remove.
 
Electronic records; so much better.
Yet when you go to any Dr, they have No Clue about your past - it is simply not provided to them in a timely, or succinct manner. Thinking the system was designed by the same who develop the Notam system.
Then we have innumerable local Dr offices shut down and they put a notice in the paper, “if you want to have any hope of getting a copy of your record, physically appear at the office by Wed”.
 
Several months ago I was called by the billing department for a local hospital to confirm my billing address for my "ER visit" at a new hospital in town. The trouble is that I was never there. I asked what I was treated for and they could not tell me because "how do we know you are you?" Initially I thought it was a scam so I called the hospital to check. Sure enough, they said I was treated in their ER but would have to come in personally to get details.

So I went into the hospital and asked to see all the records related to this alleged visit. The paperwork was not clear on what my complaint even was but it did say I was in the ER for about 20 minutes. The best part is the attending physician was listed as my brother who is an ER doc at a different hospital in town. So I called my brother and asked why he erased my memory. :D

He got on the phone to his buddy who is head of the entire hospital. It seems it was a computer glitch when they were setting up and/or testing their IT systems. I asked for a signed letter from the head of records or the hospital administrator for my records. What if the FAA had discovered it? That could be a huge hassle.

My brother is not accredited at, and has never worked at this hospital, but did once work at an affiliated hospital which is how we think his name was in their system.

How does this even happen?
 
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Is there an option for an annual "Medical History Report" like there is for an annual credit report? If so, how do we get one?
 
I've been toying with the idea of calling down to the big chain medical facility in town...since nearly all of my primary care, surgerury, and other specialty stuff has been attached to them for over two decades, and just asking the records department for a complete printout of EVERYTHING that have on me.
One reason....even though I'm set up for basic med, IF I ever did want to go back a a medical I would have zero confidence of filling out all the med visits since my last FAA medical
and now the other reason....what other crazy wrong info do they have recorded in there?
I wonder how extensive of a report I could expect from such a request.....
 
It would be digital, and extensive and largely unintelligible to the non-medically literate.
 
A lot of medical practices have a patient web portal where you can get most of your info. That's what I use to capture visits since last medical. On mine, I can get the details of each visit, including the physician notes. I have asked mine to be careful on what get's written down. No fibbing, but also no speculation on stuff until tests confirm or exclude it.
 
Jeff Oslick said:
You only have to list visits for the prior 3 years, not everything.
Click to expand...

oh I thought it was since the last medical..... but it has been a while since I did it so maybe a change...or maybe my memory is just fuzzy on it...but it does make sense to me that they would want or even need to have pretty much everything reported....just as they do for an initial medical.... "have ever in your life..."

and yeah, they have the portal thing but it only goes back so far and is fairly abbreviated at best.
 
Brad W said:
oh I thought it was since the last medical..... but it has been a while since I did it so maybe a change...or maybe my memory is just fuzzy on it...but it does make sense to me that they would want or even need to have pretty much everything reported....just as they do for an initial medical.... "have ever in your life..."
Click to expand...

They are separate questions... "Have you ever in your life..." [had one of the these conditions...]

List medical provider visits for the past 3 years (see details on the form for what actually has to be reported here, i.e., multiple visits for the same condition can be reported singularly).

For the first one, it is much better if you have a copy of what you previously reported on your last medical, so you can check the same boxes as Previously Reported, No Change (PRNC), without need to list any additional details.
 
I'm basicmed now, but the last time I got a medical I asked my health insurance provider for a printout of the previous 3 years.
 
I just saw something similar in my record with a script for something pre surgery- literally 2 pills. Even after it’s removed it’s still there. Frustrating
 
DesertNomad said:
Several months ago I was called by the billing department for a local hospital to confirm my billing address for my "ER visit" at a new hospital in town. ... It seems it was a computer glitch when they were setting up and/or testing their IT systems. ...
How does this even happen?
Click to expand...
When I did such things (one of which was a database for a very large military hospital), we had totally different, and isolated, databases for testing and for "production". The two could not be active at the same time, and one couldn't copy from one to the other. The test database had zero actual names in it! (Well, they may have been someone's name, but nobody that worked or was an inmate there.) If your record was a "dummy" it shouldn't be accessible to the system once in production. If someone merged the dummy and live databases they are incompetent.
So I'm voting incompetence.
 
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