It says I have What?!?!

Today’s post is a Public Service Announcement.

I have been working in the medical transcription field for several years, so this topic is near and dear to my heart. For years the following blurbs, supposedly from actual health records, have circulated various message boards and e-mail lists and have certainly provided a nice comic relief to many of us who do our best to decipher the words streaming from your doctor’s lips into our captive ears. By the way, if this doesn’t sound hard, imagine if the typical doctor’s handwriting could be transformed into audio. Now imagine that the paper on which that handwriting was placed was also crumpled up (static), had several words crossed out with scribbled notes in the sidelines (corrections and “oh – go back up to where I said…”). Now douse it with water for good measure (dictating while driving 60 mph on the freeway with windows down and teenagers screaming in the back seat – and no this is not an exaggeration). And we haven’t even touched on the use of exotic papers (accents). So, with all of that in mind, enjoy…

She has no rigors or shaking chills, but her husband states she was very hot in bed last night.

On the second day the knee was better, and on the third day it disappeared.

The patient has been depressed since she began seeing me in 1993.

Discharge status: Alive but without my permission.

Healthy appearing decrepit 69-year-old male, mentally alert but forgetful.

She is numb from her toes down.

While in ER, she was examined, x-rated and sent home.

Occasional, constant infrequent headaches.

Patient was alert and unresponsive.

She stated that she had been constipated for most of her life, until she got a divorce.

I saw your patient today, who is still under our car for physical therapy.

Skin: somewhat pale but present.

Patient has two teenage children, but no other abnormalities.

But wait. What is the announcement? As humorous as the above phrases are, there is also a flip side to medical report errors. The dark side is the real potential for medication errors, allergy omissions, incorrect diagnoses and so on that are  mis-dictated and/or mis-transcribed into medical records everywhere. This creates a significant risk in providing quality care to you or your loved ones.

So what to do? You have a right to obtain and review your medical record. Policies vary for facilities as well as by state, so it’s best to call your doctor, hospital, etc. and ask what their policy and procedures are. Be prepared that there may be fees involved, especially if you are requesting for several years’ worth of records. The best way to avoid this is to request your records every time you go to the doctor or have a medical visit of any kind. Again, speak to your doctor or the medical staff in charge of records. Undoubtedly, there will be forms to fill, but you get to use a pen instead of a recorder…

To your health! 🙂

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2 Comments (+add yours?)

  1. Kresta
    Oct 12, 2010 @ 11:36:30

    I have to second this service announcement. I had an experience last year when I was sitting on the exam table discussing with my doctor. He was standing close enough that I could see my consultation in his hand from a previous visit. They had my weight marked at 100 pounds more than I actually weigh. I asked him, do I look like I weight 205 pounds? He was like, “uh, no.” So I told him I owned a medical transcription service, so checking for accuracy was my job. He was more than a little embarrassed that his service was obviously lacking.

    Reply

  2. elizabethsaidso
    Oct 13, 2010 @ 21:16:39

    Did you leave your card with him? Maybe a logo pen at the front desk? 😉

    Reply

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