Author Topic: disagreeing with doctors records  (Read 224 times)

Confused

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disagreeing with doctors records
« on: September 01, 2019, 10:19:03 AM »
I have two Rheumies from the same hospital that I see or had seen for sjogren's.  The first Rheumy, who I had thought was nice at that point dx'ed my sjogren's although I had already been diagnosed by a few Rheumies.  I was hoping for a better fit.  The First Rheumy I saw from the hospital with the two Rheumies gave me a sjogren's dx, though I already had had that dx as i was positive SS_A as well as showing connective tissue disorder disease along with a few other issues.  I happened to wind up with 2 or three of the positive blood work panel for SS_A.  I was just learning about sjogren's and the first Rheumy from the hospital seemed to be nice but she said she had to switch me to another Rheumy for a time, which she did.  The second Rheumy questioned my sjogren's as the bloodwork was not done at her hospital.  (I did wind up having to see the head hematologist from a different hospital as an MRI I had evidently showed my blood somehow not flowing correctly?  I did not realize this was a see the hematologist now and had waited about 4 months to make the appointment.  By this time my blood work was fine and he said to see him anytime I needed to but for now just to watch the blood work for ay changes.  I asked him if where I had had my bloodwork that showed the high SS-A was a good lab.  He said it was perfectly good and that hospitals were now trying to get patients to go to their hospital but this was not necessary.
Jumping ahead.  I just had an appointment with the first Rheumy who now says I don't have sjogren's and she ranted and wasn't making too much sense but I figured I would not be going there again.  How do I get a letter from me put in my records that I disagree with the records the doctors have.  (The doctors rewrote the original write ups.  They show up on line and they have changed the on line write up as well)  I, however, kept a copy of every original write up.
I don't want to have a major fight over this as I am older and do not care to have any good days stuck fighting with a doctors  Any suggestions of how to handle this?  I am thinking of sending down a certified letter and having it put in my files.  Would this work?  It is bad enough never knowing what sjogren's is going to throw at me but I seriously do not need doctors going whacky on me.  If they didn't want to work with me then they should have said so.  I only saw them about once a year. 
Other doctors have taken care of other issues that I had not yet even reported to these doctors.
Thanks 

Kathy57

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Re: disagreeing with doctors records
« Reply #1 on: September 01, 2019, 10:48:16 AM »
Dear confused,

This seems strange.  I am a nurse and I was under the impression that health care workers can add updates or addendums to their original charting but they can?t erase it or change it!

I think you should be able to review all your records to see what is actually there. 

The real question is whether or not your treatment and care have suffered for this?  Are you still getting the same treatment?

Kathy
Diagnosed Sjogrens Aug. 1st 2014.  Plaqinil, Evoxac, Prevacid, Lexapro, Hypothyroid, Esophagel Reflux, Gastritis, Barretts Esophagus, failed sinus surgery with 3 nasal septal perforations.  (Can't see it from the outside)  Asthma, albuterol, Dulera, Nebulizer, Osteoporosis.

irish

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Re: disagreeing with doctors records
« Reply #2 on: September 01, 2019, 06:45:04 PM »
Good for you for keeping the original documentation. I did not catch that the first time around. I was taught in nurses training that when we had to make a change (and it had to be a small one like temperature, etc, we had to put a diagonal line through the temperature and write in our first initial and last name and then could chart the correct temp. However, as time has progressed and with all the lawsuits it did get so we could not cross out anything. Addendums used at times.

If we had issues with something it was up to us to report this to the charge nurse or nurse manager and they were in charge of follow up. It would be interesting if you could request copies of say, the past so many months of your visits. They should not have a problem with this but if they do just tell them that you need to carry the records to the appt.. If they put up a fuss then there is maybe something rotten in Denmark. I have had some weird times like this also. It is worth the time just to find a different doc and get the heck away from the first doctor.

I will add that it can be very tricky going to management and complaining about something a doctor is or isn't doing. You want to think that the management will be sympathetic but when push comes to shove there is a very fine line present. Irish


Deb 27

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Re: disagreeing with doctors records
« Reply #3 on: September 01, 2019, 08:01:17 PM »
Confused, I wouldn't worry about the "quality" of the lab that did your Sjogrens tests. Most all clinical labs are certified by the appropriate agencies. If they aren't, they usually can't reimbursement.

Also, I don't see why you would have to write a letter that you disagree with a doctor. The lab test is there in your records and so is the diagnosis from the other doctor. I am sorry. The situation sure sounds complicated between the two docs disagreeing........... I hope this clears up soon so you can have some peace about it.
Sjogrens and RA,  Morphea (skin scleroderma), Hashimoto's, 
Nexium, synthroid, HRT, plaquenil,  Restasis, Maxi-tears supplement, L-glutathionne, CoQ10, folate, trintillex,  multi vitamin. lisinopril.

Carolina

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Re: disagreeing with doctors records
« Reply #4 on: September 02, 2019, 06:51:46 AM »
I agree with Deb.  Labs may be certified, but I've read here time and again that lab results can vary when it comes to testing for autoimmune conditions. 

And I know that Doctors disagree all the time.  That's why we struggle to find the 'right' doctor for us.  I once had a Rheumatologist tell me that she hadn't even heard of Sjogren's.  Yep, that's what she said. This was in 2007, btw, not long ago.

I also agree that you don't need to spend lots of time on this, confused.  It isn't 'life or death'. And although I have an urge to keep everyone accurate, I've found that I need to 'chill out' a little bit.  I don't need to 'be understood' all of the time.

And I think doctors CAN change notes after the fact, including removing a diagnosis/changing a diagnosis.

Regards, Elaine

Female-Elaine,76-CVID-pSJS-IC-PN-CAD-Osteoarthritis-COPD-SFN-Knee/Shoulder Degeneration-SIBO-Intertrigo-Act.Purpura-Anemia-Copper Def-Raynaud's-Meniere's-Hiatal Hernia-Achalasia-IVIG Gamunex-Medrol-Gabapentin-Atenolol-Pilocarpine-LDN-Nasonex-Lipitor-Estrogel-B-12-Iron-D-Mannose-NAC-Co-Q10-D3-Omega 3

irish

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Re: disagreeing with doctors records
« Reply #5 on: September 02, 2019, 04:11:45 PM »
I have to add that I would not sent a letter to any doc telling them I didn't agree with their diagnosis. Normally, I have either told them that or they can tell from my body language. Also, I find it really rotten when 2 docs disagree enough to get the p patient all upset. Also, it should be said that the Sjogrens blood work and any other autoimmune blood work is subject to change. You can be positive one month and negative the next and the symptoms you have do not show any inkling of this.

I didn't have positive blood work until 2005 after I was diagnosed with Sjogrens with a kip biopsy. My blood work was checked every 2 years or so by my immunologist. I asked him about doing the Sjogrens blood work and he said, you had positive once and you have varying symptoms. You can run a negative blood work every so often or many times after that but you still have Sjogrens. The one blood work with the symptoms is enough.

I would just suggest that you find as different doctor and keep looking until you find one who understands Sjogrens. I started with symptoms at age 21 and was 60 when finally diagnosed. I old docs I thought I had Sjogrens and even big institutions told me I didn't. I was even told I didn't have myasthenia and I had positive blood work and symptoms.  The main thing is to find a doc who will listen to you and help treat your ailments. Sometimes one has fro go to a doc for a long time to gain their trust so that they are more apt to test for things. Doctors do see a ton of hypochondriacs so it is easy to understand how they can be slow to get on board with us.

I have had some terrible stuff said about me between doctors...... I told one oral surgeon I knew what was going on between him and a specialist he sent me to and I told him "don't you dare every do that again". I was sitting in the lobby crying prior to the drs visit cause I knew what he and this "big wig" ENT were up to. The nurse came over and talked to me. The tears just ran...I was crying cause I was so darned mad. Hubby was with me. I think I scared him too. Just remember that the road to diagnosis can be filled with misery at times. I wish I had kept a big journal!!!!

Just to let everyone know that this junk does happen and I am still of the opinion that moving on to a new doc is the best way to go. I wish I had kept track of all the docs I saw...and dentists. All I can say is to just hang in there and call your experience what it is. Visits with 2 darned fools. Pardon me. I have always wanted to tell a doctor that when his wife or Mom got Sjogrens then he would take it more seriously. Hang in there. It is frustrating beyond belief. Dealing with the symptoms is the important thing to start with and get the ball rolling with a new doctor. Good luck. Irish


katie1111

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Re: disagreeing with doctors records
« Reply #6 on: September 03, 2019, 04:30:18 AM »
I agree with Irish - find a doctor you can work with.  We have enough things going on to upset us without adding our doctor to the list.  Remember that aggravation makes our symptoms worse.  I doctor shopped for quite a few years until I finally found a family practice doctor.  He is one of those concierge doctors who you pay upfront extra money and you gain access. For me, he is worth it.  He guarantees a 1 hour physical per year, and more important appoints are 1/2 hr.  That gives him time to actually listen and deal with all my complaints.  Since he has a limited number of patients, he as time to personally research weird symptoms and he calls the specialists and discusses my case.  He told me he has a large number of patients with rare diseases as they have not been able to find a doctor who has time to deal with their symptoms.  This might not be the right choice for you, but my point is look until you find a doctor you are comfortable with.  That, alone, will decrease your symptoms.

Katie1111