Doctor's after visit notes have so many inaccuracies and come across as demeaning

[Anonymous]

OP, i always review doctor's notes after my appointments to make sure i remembered my to-dos correctly and check on test results. I would be annoyed by things you listed here. And yes, i wouldn't trust this doctor.
Time to find a new one.

[Anonymous]

The doctor’s emr likely guides them through a note for the diagnostic code they indicated and those statements are populated based on them clicking various boxes. Obviously, they shouldn’t be clicking in anything not true! However, since you did briefly discuss Mediterranean diet and she agreed it was excellent I am not dismayed she clicked that button. If you are or if there are lies then switch doctors (but you will find similar language in their notes.)

[Anonymous]

Anonymous wrote:Doctor wrote that a former doctor of mine diagnosed something that was never diagnosed. It's not a huge deal, but it is annoying. She also wrote several other inaccuracies. [/b]These need to be corrected.

Also wrote things like "Educated the patient on the Mediterranean diet" when I told my doctor that's the diet I've been following for the past few years. She didn't educate me on it, just agreed that it's a great diet to follow. [b]Diet education is liekly billable

I have slightly elevated cholesterol and this is nothing new. I've been following this diet for a long time and my cholesterol lowered by 20 points in my most recent labs. (I'm 20 points over what I should be in my overall cholesterol). She didn't even note "Your cholesterol is down from the last time." Just said "Your cholesterol is high, but not high enough to start medications." I'm 80 points below what it would be to actually start a medication. They dont give gold stars in clinical notes. It would only be indicated normally if it put you in a new category. For example, patient lost 30lbs moving from overweight to normal BMI. Discussed strategies to continue/stabilize weight loss.

She is a newer doctor and the way the notes were written, it seems like she's trying to boost herself up in the notes. I don't feel comfortable with this doctor anymore. On one hand, the inaccuracies were not a huge deal but it makes me feel less secure with her. Would you feel this way or am I overreacting? I feel like if I were to have a major medical issue, I wouldn't feel confident with her.

If you dont trust her get a new one. Simple. [b]

[Anonymous]

You sound like a PITA patient to be harping on what are essentially style points. Move on bc if this bothers you she will be lucky to be rid of you.

[Anonymous]

Anonymous wrote:You sound like a PITA patient to be harping on what are essentially style points. Move on bc if this bothers you she will be lucky to be rid of you.

I disagree. The doctor was lying in the notes. Not cool.

[Anonymous]

Anonymous wrote:

Anonymous wrote:I hate the notes and I have a lot of them. I think there is a lot of boilerplate that the docs have to check off in order to meet their metrics. Mine have a lot of “patient indicated understanding” “patient indicated she had no further questions at this time” and my favorite “emotional support provided”.

I would not let it keep me from a doctor I really liked but take it as yet another indication that doctors are mired in bureaucracy instead of patient care.

I understand that. I have to write clinically as well because I'm in the medical field myself. It can make you cringe when you read that stuff about yourself.

I'm talking more about inaccuracies - blatant ones. I never told her a former doctor diagnosed the thing she said was diagnosed. It just never happened. And that concerns me because if I go to another doctor in the future, they could see that and think "Patient has a history of x" when I don't.

Some of it is probably because of insurance. I had one doctor who told me that he was writing something a certain way in the chart because of insurance. I've seen other inaccuracies in notes that I assume are there because the insurance company wouldn't cover it otherwise.

Either way, our for-profit health-"care" system is the culprit here -- either because of what I'm describing or because it attracts people who are driven primarily by high salaries as opposed to public service.

[Anonymous]

Anonymous wrote:It’s a combo of legal CYA and confirmation that many doctors believe that women, especially middle aged and above are hypochondriacs who are just wasting their time.

X1000

[Anonymous]

I just recently read my notes. My PCP has a transferred file from when I went to my first adult doctor after being with my pediatrician from birth until 18.

I was shocked to learn that I had been diagnosed with things as a kid that were never relayed to me by my parents.

I thought my file had been mixed up with someone else's file. I asked my mom and her excuse was "it was a different time. Having an autism diagnosis would have stigmatized you and held you back."

Um, yeah. That's right. I was diagnosed as autistic, with OCD tendencies, and anxiety. I remember going to several doctors as a kid but never really understood why. My parents always told me it was because I was so smart.

My parents never did anything with that information because I was a smart kid who did well in school. "If you'd struggled, yes, of course, we would have gotten you help. But you didn't! You thrived and didn't get limited by some stupid stamp in a file."

Well, that information sure would have been helpful to know when I had a near-breakdown in college with anxiety so crippling that I felt like I was dying just leaving my dorm room.

[Anonymous]

Anonymous wrote:I just recently read my notes. My PCP has a transferred file from when I went to my first adult doctor after being with my pediatrician from birth until 18.

I was shocked to learn that I had been diagnosed with things as a kid that were never relayed to me by my parents.

I thought my file had been mixed up with someone else's file. I asked my mom and her excuse was "it was a different time. Having an autism diagnosis would have stigmatized you and held you back."

Um, yeah. That's right. I was diagnosed as autistic, with OCD tendencies, and anxiety. I remember going to several doctors as a kid but never really understood why. My parents always told me it was because I was so smart.

My parents never did anything with that information because I was a smart kid who did well in school. "If you'd struggled, yes, of course, we would have gotten you help. But you didn't! You thrived and didn't get limited by some stupid stamp in a file."

Well, that information sure would have been helpful to know when I had a near-breakdown in college with anxiety so crippling that I felt like I was dying just leaving my dorm room.

You were going to have the breakdown anyway. It's not your parents fault.

[Anonymous]

Anonymous wrote:

Anonymous wrote:You sound like a PITA patient to be harping on what are essentially style points. Move on bc if this bothers you she will be lucky to be rid of you.

I disagree. The doctor was lying in the notes. Not cool.

It’s not “lying” to say you discussed the diet and the fact that you are nitpicking over the word “educated” which is just a box-checking thing for the doctor is ludicrous and bizarre. Plenty of doctors have high self-esteem and write things in a way you might find “self-promoting”, when creating a record of their own work which in case you are confused on the point, is what this is. That she said your cholesterol was still high but not needing mediation despite it having dropped a bit, which apparently was not your cup of tea but is still accurate, is such a silly thing to get upset over. She is not a match for you (and vice versa). But you need to understand that your medical notes are not a diary entry or a letter to you the patient. They historically were to document the physicians thought processes to themselves and each other and were the property of the hospital to which you had no such access until recently. You are basically eavesdropping on what used to be a private conversation.

[Anonymous]

I read my notes from a recent hospitalization and I think I'm more upset with my husband although whoever wrote down what he was saying can't have given it a lot of thought either. There are things like "the husband instructed the patient to go back to bed" when I had supposedly passed out on the living room sofa at 2 am.

[Anonymous]

Anonymous wrote:

Anonymous wrote:You sound like a PITA patient to be harping on what are essentially style points. Move on bc if this bothers you she will be lucky to be rid of you.

I disagree. The doctor was lying in the notes. Not cool.

+ 1

Correct the notes, send an email with both her notes and your correction. Tone should be respectful. Ask also who should you be sending the email to, if the doctor cannot correct her notes.

Speak out once, politely, firmly and in an email. I will guarantee that you will never have a problem again.

[Anonymous]

Very dumb question here. How are you all getting these records? I've never seen drs notes in my life.

[Anonymous]

Anonymous wrote:Very dumb question here. How are you all getting these records? I've never seen drs notes in my life.

You’re allowed to ask to see them now.

It’s been terrible for medical practice as the chart used to be a place where people could say what they think and what they are considering and their thought process etc and now the society is so litigious and with people like OP pasting every word, the chart has become just a CYA & billing document and lost so much of its original true purpose and meaning. Medical writing used to be practically its own literary genre and now you can hardly say what you think.

[Anonymous]

^parsing every word