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Old 03-11-2008, 12:50 PM   #1
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Why Do Doctors Not Report Everything in Medical Records??

Okay, I had to get my medical records relating to my back. I've gotten some, but not all, of course one office isn't returning my phone calls; another did speak to me, told me to mail my request, but havent mailed my records back yet. Anyway...in reading through these reports, Im seeing that many times things either aren't reported correctly or were never done. FOr example, when i've got my nerve block and lidocaine injections, both docs reported I tolerated them well. Well, that is not true!! My nerve block, I almost went through the roof with my left sided sciatic pain even worsened; with the lidocaine shots, they hurt like hell b/c I was usually in spasms. Another doc reported my temp & blood pressure each time, but they never check these things. I complained about fever once, my temp wasnt checked & it wasnt even mentioned on any reports. I also see I am diagnosed with SLE (lupus), which I wasnt sure of all this time. Aldo x'd with Fibromyalgia. Last time i was there, it was reported I had multiple fibro tender points, but there was no exam done at all. And I believe where I am tender is where I have spasms. It also said I have bilateraltroncheric bursitis, no idea what that is either, and bilateral SI joint arthritis and cervical spondylosis. Geez, and it also notes iv'e been injected with lidocaine PLUS Kenalog (which I believe it a steroid). If i've gotten kenalog with every lidocaine injection, no wonder i cant lose weight. Well, none of those ever did me any good except for one shot in my ankle once. But i have gotten probably 8 to 10 shots each visit all up & down my spine, in my left shoulder, and rear end.

At least nothing shows they think I was faking anything. But most of the records I got are from before surgery (except rheumy & one urgent care place). My new PM"s office isnt calling me back to get my records of recent ESI's & one urgent care hasnt sent me my records. Im not going to worry b/c I guess I can authorize Voc Rehab to get those records. They said to bring what records I can and if not, bring names & addresses of all treating physicians. I'm also getting my PT records, though most of that is from before surgery and just after when I was doing pretty good. Now had I been seeing them thru my insurance where the PT sends reports to my docs, it would have been noted everytime I had pain or a new problem.

But anyway, Im pretty much just venting..I just wonder why some things arent noted correctly, or wrong, or missing. It really irks me.

Well, I have all those other conditions listed in my one doc's reports, so maybe that will end up helping me in regards to voc rehab. Plus I havent had an MRI since May '07 and things have gone awry since then. My appointment is this Thursday, so I shall see what they think. I didnt go there on my own, I was referred by someone. And when someone in UE showed me jobs for police officers, or retail employees, I told them I cannot stand long & wouldnt be able to those sorts of things. (I wouldnt work in retail again anyway) So they led me to Voc Rehab, who said if I qualify, they will be able to help me find a job and maybe get me more training.

 
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Old 03-11-2008, 01:34 PM   #2
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Re: Why Do Doctors Not Report Everything in Medical Records??

with you talking about voc. rehab..makes me think of workers comp???

i dont know if its wc drs..or all drs. but mine done the very same thing. said i tolerated and even got better from epidural steroid injections...when the 2 & 3rd one didnt even phase me at all!!!!!!!!! after the 3rd one..i was rated/released from the wc dr care..but 1 month later..i was back in there and then was referred to a surgeon...and on my very first MRI report it showed 2 bulging discs and one rupture....BUT...i never knew about the other 2 discs until i got a copy of the MRI report myself. i just dont get why wc drs are like that...they should be FOR the patient regardless of who is paying the bill.....they say that the drs are to hurry up and get you back to work asap...BUT...if they dont treat your injuries that actually show up on exams/reports, etc....how is that helping anyone?? all thats going to do is make your health worse when you are put back to work...to where you have to make another claim again! they IRRITATE ME!!!

 
Old 03-11-2008, 01:42 PM   #3
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Re: Why Do Doctors Not Report Everything in Medical Records??

Medical records aren't always what they seem, are they? When they say it was tolerated well, that just means that you didn't have any serious complication, like passing out or heart arrythmias, or something like that. Most doctors don't put things like "injection caused extreme discomfort" or "patient had unusually high amount of pain." They don't consider that to not be tolerating it. Go figure. They have a whole different understanding of some basic English!

I hope the Vocational Rehab works out for you. The best part is that they help you land a job, too! Yea!!!

Hope your spirits are okay as you continue to walk through all these hard things at the same time.

Take care,
Emily

 
Old 03-11-2008, 02:09 PM   #4
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Re: Why Do Doctors Not Report Everything in Medical Records??

Hope all is going well for you...they should be testing you to see what you may be "good" at...then if additional courses (college) are needed..well they take care of that for you.. I had so many tests it wasn't funny...at each step of the way. there were less and less people in attendance..guess they gave up...NOT ME...Those who kept going finally got the training. Think of something you may like to do...and that your body will allow you to do. Can you type??? Medical records is goods...billing is also good...if you can sit..for a while.. Pay can also be good for either of those occupations...there are courses for them also. I did business mgmt. & marketing...I love to talk!! (also I run off at the key board a lot too!!!). I wish you luck...and much success...

Leslie

 
Old 03-11-2008, 02:13 PM   #5
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Re: Why Do Doctors Not Report Everything in Medical Records??

Great question! We may never know why Dr's do that. I just got copies of my records from one PM doctor (as I'm applying for SSD) and he states I have Fibro...News to me!
My GP is very good on reporting he even states when my hubby goes with me!
Cindy

 
Old 03-11-2008, 02:16 PM   #6
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Re: Why Do Doctors Not Report Everything in Medical Records??

Hi Baybreez...don't know why they don't put everything in our records. I have noticed this also. Also, every MRI I have, the reports says something differenct... Sometimes, the doctor doesn't put in what concerned us during the most recent appt. Just their thought process...and I don't agree with some of their thoughts!! Nice to get a look at the reports once in a while..just have to not take it all too personally..don't understand why...but that has happened...maybe it was frusteration!

Leslie

 
Old 03-11-2008, 04:27 PM   #7
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Re: Why Do Doctors Not Report Everything in Medical Records??

Ladybug - oops, sorry I should clarify this. I am not now nor ever have gone through worker's comp, as I never got injured on the job. Mine is all degenerative. What happened was, my company in mid January layed everyone off (except a handful to tie up loose ends) because they are going bankrupt and closing the company. So I am on unemployment. I was very concerned about finding a new job with a visible walking problem and stiff right foot (due to wearing a brace). BUt I apply anyway, though I've only been called to one supposed interview, but it turned out not to be an acutal interview. But I could see people staring at me as I went in and, tried to get up afterwards (being so stiff) and as I left. It's very hard b/c when something is visible, how many jobs really want to hire me? And of course they would just claim I wasnt the right one for the job, blah blah. Actually I had told my bankrupt employer that I had some medical issues but they hired me anyone, though I had no back problems at that time, it was something else. Anyway, while at a unemployment meeting, a man came in and called out my name, and told me to see him when my meeting was over, so I did. He asked what I did to my leg, but I just didnt say much back. He was showing me job websites, gave me some things, etc...and gave me a flyer to be a police officer (LOLOLOLO yeahhhhh right) and showed me jobs available in retail stores (another yeahhh right). I just had to tell him I cannot do any sort of stand up or physical jobs. I did say I can work & will work, just not anything like that. So then he brought me to another area of the bldg, which turned out to be Vocationa Rehabilitation Services. He told them that they might be able to help me. So I filled out a short application form and had to fill in my disabilities. Someone came out real quick and said if I'm being treated by docs or have records of being treated for it, they might be able to help me find a job and maybe even get me training to improve or update my skills.

So it wasnt' even anything I had asked for, and none of my docs knew anything about it ahead of time. I just asked for my medical records for anything back related. Though maybe I should have mentioned my ankle problem, too. (But my ankle does pretty well usually with this brace I now have).

But at least I knew there would be records of my pain & symptoms since after my surgery. But 2 places I went to either havent returned my calls or havent mailed my info. (unless it went into someone else's mailbox, which happens alot around here).

So i have a meeting this Thursday with a Voc Rehab person and i'm supposed to bring any medical info I can. Maybe they can get my info from the places i've not yet gotten it from.


Blue - ahhh, thanks for explaining that to me. I would have never thought of it that way, but I guess it kind of makes sense. Yeah, I bet these docs would think alot differently if they felt the pain we do when having some of these procedures done! THanks for the well wishes.

Sage - one of my former co-workers looked into training through unemployment (well actually it's through re-employment services) She said there were alot of tests and she took them, had meetings with this one & that one, etc. She said she did well, and was then told there are no more funds for training, so she'll have to be put on a waiting list in case funds become available again. The funds were stoppped just recently by our Governor I came to find out. But I have no idea if no funds are available in Voc Rehab either, guess i'll find that out soon. In my area, there is a plethora of all kinds of jobs medical related. It would be great if I could learn med. terminology and/or coding. Yes, I can type and my job was sitting down for the most part...typing, phones, taking care of orders, etc. Also, there was no mention of my widespread cramping & spasmsing in my last visit. ANd he even noticed it in my hands and that's the reason he sent me for bloodtests. But the notes for that day mention nothing about it, whatever. It didnt mention anythign about my migraines either & he even prescribed the imitrex.

Happy - my rheum mentioned Fibro when I first went to him, but since then iv'e gone through all these back problems and I really think my muscle tenderness is due to spasms, not fibro. BUt of course im not a doc, its just my observation.

So whatever, it is what it is, but it still irks me. Especially, what if, like many of you, it was for worker's comp or something else. What if I need proof of some things down the line and now it's not there in writing?

 
Old 03-11-2008, 05:21 PM   #8
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Re: Why Do Doctors Not Report Everything in Medical Records??

Hey Baybreeze I just wanted to say Hello. I am really glad to hear you are going to Vocational Rehab. I had a great experience with them and I am 99.9% certain you will qualify. One of the many things they can help you with is getting medicaid and applying for SSDI if you are interested in that. They also do a lot of testing to see what might be a good fit for you. I remember doing a test with a professor that was for spatial relationships and that is not my strong point by a long shot. I was shocked that you said your records say you have lupus and that is not being followed up. Id be following up on that for sure. Good Luck with your appointment and I will be interested in what you find out. Dee
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Old 03-11-2008, 08:48 PM   #9
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Re: Why Do Doctors Not Report Everything in Medical Records??

Hey Bay, I don't think I have fibro...but was very surprised to see it listed and that no Dr ever told me I had it....Good Luck to you and the new training!

Also, one more thing about items being listed in your medical records...now get this..(it happed about 15 years ago) I went to my GP for back pain after surgery...I can not walk...I wait two hours in the waiting room then ask again how much longer...the nurse says it will be about another hour so I tell her I am leaving and going to the ER...The next time I see my Dr for an appointment the nurse wrote in my chart that "Patient left and refused to wait to be seen" Not what happened at all! I made the DR correct it was I watched!! He was very apologetic as he had no idea she had written that in there....So sometimes it can be the nurses fault!

 
Old 03-11-2008, 09:51 PM   #10
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Re: Why Do Doctors Not Report Everything in Medical Records??

I know what you mean. I have a workman comp suit for my elbow. Occupational not accidental. Every time I would go to therapy they would say how swollen it was. How they could not believe how bad it looked etc. They never wrote it in their notes. All they wrote is "patient complained of pain" and stuff like that. When I had to go for my other elbow they had done everything they could. It came time for the therapist to request more visits. So she said it probably would not help. So I told her then don't bother. I told her make sure she did not write that I refused further therapy. I could see her doing it.

 
Old 03-12-2008, 07:02 AM   #11
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Re: Why Do Doctors Not Report Everything in Medical Records??

Dee - yea, I can work, just have to have a desk job. So being that I can work and do want to work, I won't bother with SSDI and such. I probably wouldnt qualify for that stuff. I bet I would have even been denied it before surgery when I was wayyy worse. Really, I do want to work, I just have to hope I can find an employer as understanding as my last, especially with needing to leave constantaly for all sorts of doc appointments. And that they can look past whats visible b/c I know I put my all into any work I do. At least I do have a letter of recommendation from my boss, hopefully that will help some.

Happy- my doc told me about the fibro and lupus (then it seemed like he didnt think I had lupus, so i wasnt really sure)..but one report says my SLE is being controlled with meds. ANd that was ridiculous that you waited all that time in the waiting room and to have them put that you refused treatment!! That IS bs! Im glad you had that straightened out.

Hessie - I dont blame you for telling them not to write that you refused it. It just seems some would rather make things seem like a patient's fault than something they did or thought. Then again, that happens all over in life, not just in medical settings. But the problem is, what if you did need to apply for some program, and they see that in there, that someone refused treatment and things like that. Then it looks like you're doing somethign wrong. Ahhh, it still irks me somewhat, but i'll get over it lol


Thanks for listening and for all your replies!

 
Old 03-12-2008, 08:57 AM   #12
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Re: Why Do Doctors Not Report Everything in Medical Records??

[QUOTE=BlueAtlas;3481891]Medical records aren't always what they seem, are they? When they say it was tolerated well, that just means that you didn't have any serious complication, like passing out or heart arrythmias, or something like that. Most doctors don't put things like "injection caused extreme discomfort" or "patient had unusually high amount of pain." They don't consider that to not be tolerating it. Go figure. They have a whole different understanding of some basic English!

I hope the Vocational Rehab works out for you. The best part is that they help you land a job, too! Yea!!!

Hope your spirits are okay as you continue to walk through all these hard things at the same time.

Take care,
Emily[/QUOTE]

Good point. To me not tolerating well would encompass all of the above, including but not limited to the high amount of pain. But I can see how in doctor lingo they would exclude all of that except for the serious stuff. But to us, living with chronic pain, I wish they would take the time to dictate through detailed notes.

Lori
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Old 03-12-2008, 08:50 PM   #13
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Re: Why Do Doctors Not Report Everything in Medical Records??

Often medical records only report the minimal information. Saying you tolerated a procedure well means you came through it with no immediate effects (for example, if during the procedure you got very ill and unable to walk out - then they'd not be able to say it was well tolerated). So even if you are in pain, if you survive the procedure you "tolerated it well".

Also there are many abbreviations used in records that may need to be considered. For example, if it says r/o SLE - that would mean "rule out lupus".
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Old 03-13-2008, 02:55 PM   #14
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Re: Why Do Doctors Not Report Everything in Medical Records??

i just wanted to mention something about your medical records? ALWAYS,like every year or two or sooner depending upon how often you are actually seeing your docs,obtain you very own set of all of themi update mine once or twice a year now). this would also include the medical records from any actual surgery or hosp stay? i can almost guarentee just about anyone who has been treated for an ongoing chronic type of condition that if you actually looked thru them all,you WILL find things wrong. its just the way things unfortunetly are. i found out when i got turned down my first go round for SSD that my records did not contain actual conditions and syndromes i had been actually Dxed with,but the worst thing was a very very important document that was needed to prove that my nerve loss and the damaged ones actually occured during my spinal cord surgery. wasn't even listed at all in my neurosurgeons op notes only becasue i been told BEFORE the surgery that i would most definitely lose fine motor function and nerve loss to my legs. so this was an "expected outcome" according to my NSs op notes and by surgical standards. i knew before it occured that this was going to be a huge loss,so it was considered a 'normal" surgergical outcome which is the box my NS checked on the dang form. this was despite major devistation for me.

i spent like weeks just trying to track down the neurophysiatrist(first i had to find out his freaking name then where he worked out of) who actually did the monitoring of my motor and sensory functions during my surgery to get HIS op notes which thankfully told everything. the thing is,this documant was supposed to be in my central medical file at the dang hosp where that surgery was done and it was missing? hmm.

after really obtaining all my records after that initial turn down by SSD,i had an amazing experience in just reading thru all that had not been documented and things that were in them that i NEVER actually had been Dxed with.

there are a few different reasons for the problems when you consider that these are transcribed by someone who is doing this like all day long,who could very easily confuse something from someone elses records with yours. also,the docs have the very same issue since they are seeing tons of patients all day long and can also confuse patients too. i must see my primary doc at least once per month,sometimes even more,depending upon the malady du jour,and he still will make an occasional mistake in my records from time to time too. its just the nature of what goes on and how your records become that permanent record that is also governed by mere human beings who DO make mistakes.

this is where you come in and go thru your own stuff from time to time so you can catch the mistakes and have them corrected. if you ever actually try and apply for SSD,i would very strongly advise you to obtain every single record yourself FIRST,before you actually apply so if anything is actually wrong or just plain missing,you can get it corrected before SSD actually gets them or it could come back to bite you like it did with me. if there are any mistakes in your records,they just really need to be fixed by sitting down with the doc that screwed them up. it really can be a very bad thing for you if things are not right in your own medical records,in many cases,depending upon who needs to see them and for what purpose. i learned this the hard way. if you obtain them and something is actually wrong,get it corrected as soon as possible. you just never know why you may need them or when and everything has to be correct in order for you to just get your needs met. i will always obatin all my records now til the day i finally croak. its just THAT crucial for some of us. Marcia
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Old 03-14-2008, 05:58 AM   #15
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Re: Why Do Doctors Not Report Everything in Medical Records??

Feel, i'm sorry that happened to you. I was thinking the same thing, what If I was applying for that? Or anyone else, just like in your case. Some things were wrong, some missing, etc. Plus , if one has a bunch of different symptoms and hasnt been diagnosed, it makes things harder for a new doc to look things over if things were never put in one's records. I know I wish I had my records since my other problems started b/c every time I went to see a new doc, they didnt know me from adam & could only go by what I told them or remembered. But yes, you give some good advice with a good example of why anyone should check their records.

Its like one back and nerve pain episode I had last summer, I was feeling hot all the time (when I was always usually ice cold). I went to a walk in place one time w/ severe nerve pain, they took my temp & I had a low grade fever.
I was also getting pain in my heels, that's when my eye problems started and I got rashes in a few places. Then I started taking my temp after that, and I did have a fever for over 2 months along with my back pains, nerve pains, and other symptoms. I went to my rheumy b/c then I started having hand pain, told him of my fever & other stuff....but none of that was in my records at all. No one even checked my temp that day, but I guess they just put any # on it to fill in the space. And my thinking is, what if all my symptoms are connected in some way and I went to another doc? He might think I was making things up. Just like with you and SSI.....if something was missing, they probably think you're lying or something and look, it got you denied. I guess some docs don't realize how important these things can be for someone in the future.

 
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