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Help Please - What to do about progress note/s that get sent to the doctor you are being referred to

Discussion in 'General ME/CFS Discussion' started by Jennifer J, Nov 11, 2015.

  1. Jennifer J

    Jennifer J Senior Member

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    Southern California
    Hi. I'm frustrated and at a loss again with how to go about things so I can get the treatment I need and not be stereotyped.

    For many reasons, I need a new endocrinologist. My Endocrinologist's progress notes on me are shocking.

    I thought she was kind, compassionate and intelligent. That she heard me and understood what was going on medically with me. She never gave me any indication that she didn't until I read my progress notes. Why did she just nod and agree, and tell me one thing and then writes other in my chart? I'm a thoughtful, intelligent, rational person that can handle honest dialogue about what is going on with me medically. Pleasant and intelligent are words a few doctors have used to describe me.

    My experience is that if I write something to include in my medical chart, it will not be included in whatever is being sent out. The doctor's office chart has a section for different correspondence and protocols about this. (This also happened when fighting for SSDI, none of my notes which were given to the doctor each visit was sent into them, which I didn't know until years into the process.)
    Also, I'm concerned that it makes it look like I could be a problem if I'm saying something in contrast to what the doctor has noted, so the doctor I'm being referred to may not accept me or will form this preconceived notion of who I am.

    As we do, I have so little cognitive and physical energy and ability to do this. I'm pouting and waahing again that I have to deal with this when so much other needs to take place. I need to go about this the best and most concise way.

    I'm so thankful for this site, for all of you (even though I'm sorry that you are living with this, my heart goes out to you all), and thankful for being able to reach out here and be there for each other along the way.

    Does anyone have suggestions? Thank you.
     
    Last edited: Nov 12, 2015
  2. minkeygirl

    minkeygirl But I Look So Good.

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    Left Coast
    I had a problem once with my file. I wrote my own letter addressing Her comments to put in the file. I don't know if she did.

    A few months ago I saw what an allergist/immunologist said about me. Basically I had psych issues. I wrote a rebuttal and gave it to my pcp. I did not send it to the offending doc because i don't want to deal with him again.

    Maybe call the AMA and see what they suggest?

    To guard against this, and you now have me thinking, request copies of your file periodically so you can see what they write.
     
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  3. CFS_for_19_years

    CFS_for_19_years Hoarder of biscuits

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    USA
    Does the clinic where you were seen have a medical records department? If so, ask if they have a form to correct information in your medical record. The corrections and/or additions you make are called an addendum. See the form I've attached here to get an idea of how it works.

    It once took me two months to prepare a response to a really confusing medical report made by a pain doctor. She didn't understand how some injuries occurred and she thought they were all related, which they were not. Her response to the addendum was kind of huffy but I let it go since the important thing was to document when and how certain injuries occurred.

    The addendum should make it into your medical record and not get shuffled off into correspondence, at least I hope not. Once when I pointed out to a doctor via email that he'd mentioned the wrong drug in his report, he could not go back and change the medical record itself, but he could write an addendum, which he graciously offered to do.

    I think even if you want to add information and not necessarily make a correction, you should be able to do that, and it would probably be helpful to mention why that information is important as you're writing the addendum.

    Although this is written for providers, some parts might be helpful:
    http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_044678.hcsp?dDocName=bok1_044678
     

    Attached Files:

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  4. Groggy Doggy

    Groggy Doggy Senior Member

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