Privacy Violation--Venting!

[Patze]

I also agree with the others, you've done nothing to be upset about; the error is not yours, it's theirs.  Don't feel bad about reporting this clinic, these folks need to change their operation fast - I'm just amazed that they've lasted this long doing this crap. 

Patze

[Reenie]

Thank you everyone .  I do just want to do the right thing.  I really appreciate the support, reassurance, and advice from all of you.

I'll keep you posted.

Reenie

[SeaBreeze]

Hi Reenie,
I'm sorry you are having these issues with what should be protected information.
I'd like to suggest that if and when the doctor corrects the reports that he/she state clearly in the dictation that this is an addendum with corrections to report dated thus and such".... and that the doctor who dictates, signs in ink, not an electronic signature or other form. In a perfect world you should be able to sit with the doc and go over said reports, make corrections together prior to doc re-dictating... I've worked in medical records depts and additional supposed 'corrective reports' shoved into a record is confusing to anyone reviewing the record... Good luck with everything... its definitely a bad circumstance...

[Reenie]

I will definitely take your advice about the addendums to my medical records, Seabreeze. Thank you!

I wish all doctors were as wonderful as my ENT.  He does the dictation immediately in the exam room while I am still sitting there after the exam, and he does that for all of his patients.  He is the only doc I have that does that, and I think it is awesome!  For one, the patient can correct any mistakes right then and there before it ever gets transcribed, and also his memory is absolutely fresh.....no chance of mixing up info from the previous patient(s).  I have only positive and great things to say about my ENT.

Thank You,
Reenie

[SeaBreeze]

You make an excellent point about dictating immed after appt.  Some doctors wait till end of day, or end of week. I think a lot of details can be missed this way... There are a lot of doctor offices that are in between 'paperless' medical record keeping and hard copy note taking... and it takes awhile for everyone to be on the same page (no-pun)...
When patients are admitted into hospital dictation and transcription is another story... when I worked in med rec dept years ago, some docs would be so behind on their dictation the hospital could pull their privileges and they are not allowed to see patients... If its a teaching hospital, attending docs sent resident docs to Med Rec dept to do their dictation even if they haven't seen the pt before... Residents simply 'read' and dictate from the attendings handwritten notes.. sometimes there would be literally 'piles' of charts that needed dictation.
Transcription of these reports is difficult. Doctors speaking too fast, running over key words, some docs with accents, eating chomping and coughing while dictating... Then there were the statements that you said to yourself do you really want to say that the "patients blood pressure was 200/200 which is normal for the patient"...  Another issue were 'shortcut keys, or micros' that the transcriptionist could set up on their computer; for instance if you typed sbo; small bowel obstruction would automatically appear, that one makes sense but many of these micro strokes were set up w/out consistency, would pass a spell check and grammar check, but absolutely no sense in the statement... Doctors use these also; for instance at my Endo, my instruction sheet that I get at the end of the visit says "We spoke about your hypercholesterol discussed low fat diet etc etc. He didn't dictate that, he prolly typed in hyperchol and those patient instructions were filled in automatically ... Sad thing was we NEVER discussed my cholesterol at all... and under "foot exam" it said 'normal' and instructions for at home foot care was there, sad thing is he NEVER looked at my feet and if he had I would have mentioned my numbness and that would not have been normal... it makes me crazy ... But there is a mix of people to blame...
YIKEs... I've gone on and on... sorry, but its a pet peeve of mine. And I hope it helps some...
I guess my headline is... Like a lot of you, I get copies of all of my notes and labs etc. If something seems wrong to me, I bring a copy with me and discuss it on the next visit... A few weeks ago while 'filing' my lab stuff I came across my folic acid result which showed a significant deficiency which was overlooked, I called and am now on folic acid supps...

[KathyG]

Hi Reenie,

Wow, sounds like you have the right idea in looking for another health care provider.  What they did is called a data breach, and depending on where they're located they may be required by law to contact the party whose data was revealed and let them a) know what happened, and b) what steps they'll take to keep this type of thing from happening in the future. 

If you haven't yet done so, I'd recommend contacting your state (or equivalent) health department or board of medicine and bringing this plus your other issues to their attention.  Sounds like that place needs a wake-up call.  Someone there may have advice on a course of action.

Good luck!

Kathy

[Bucky]

Reenie, I thought of you at 2:00 a.m. this morning.

Last night I went to the ER with chest pain.  After I was sent home at 12:45 a.m. this morning we stopped to get a bite to eat.  I ask my husband for the discharge paperwork they had handed to him.  First thing I notice . . it's got someone elses name on it!  It also has some of their meds and some of mine.  No where on this paperwork did it have my name.  Although, it DID have some of the information that the doctor told me about my visit to the ER.  Hmmmmmm . . . I instantly go back to your experience.  I was too tired to bother calling them at 3:00 a.m. but DID call them at 9:30 a.m. this morning. 

I explained the situation and said I would like a copy of MY discharge paperwork and told them I hoped that the wrong information wasn't sent to my PCP or put into my files at the hospital.  I was told that I would could get this report but I had to come in person and sign a release for it in medical records.

So, we head back to the hospital and go to medical records.  Again, I explain the situation and they were very prompt in checking into the matter.  (And I'm thinking to myself in the meantime . . yeah, they want to cover their butts!!!!)  The lady assured me that MY medical information did not go to anyone else.  Their explaination was that there were two patients in ER with the same complaint at the same time and that we were released at about the same time.  Thing is - the other patient was male and 38 yrs. old, I am female and 51 . . . our names are nothing alike. 

Long story short . . I do believe it was a mistake and I hope they have put the right information in my files.  They did give me a copy of the complete medical papers for the entire evening.  I have read them and they are all the information that transpired during my visit to the ER (with just one little boo-boo . . in one spot they have me as male instead of female, but it was corrected in a later entry).  (Probably happened after the chest exrays!!  LOL   )  The gal in medical records did ask me for the paperwork I received at discharge.  I had made a copy at home before heading to the hospital so I gave her the "originals" I had been given. 

Next week at my doctors app't. with my PCP I will check to make sure the information he was sent from the hospital is correct.

Bucky

[SeaBreeze]

Their explaination was that there were two patients in ER with the same complaint at the same time and that we were released at about the same time. 

Yikes that would be a lame excuse at the hospital I used to work at; chest pain was one of the top complaints of people presenting to the ER.

I'm glad you have the correct information...
If you are up to it, maybe consider sending a note off to Director of Emergency Medicine and the Director of Medical Records... This is important stuff they're fouling up... and your complaint may never be brought to their attention.
Take care...

[Victoria05202000]

Oh my!  Yeah can we say HIPPA??  I work for a hospital and we would be in a hoop of trouble....so much I shudder to think of it. !!!  AND as many problems as you have had....TSK TSK!  I know we are human and are subject to err, but your situation is ridiculous!  The office/hospital should be reporting EVERY little mistake out there.  Are you in the USA?  You need to look up Healthgrades or Joint Commission on your local hospitals and doctors that affliate with them.  They will tell you the better places to be treated.

I hope you get the help you need.
Take CAre!
Vicky

[Bucky]

Vicky - yes, I am in the US.  This is the first time I've ever been to this hospital for medical treatment (thanks to our new insurance that won't let us go to the hospital of our choice ).  I must say, I did receive good care at the hospital - it's just their paperwork that wasn't quite up to par.  I know that's no excuse and the nature of their business it's important to have accurate information.  Believe me, from now on I will check things out myself before leaving!  (I hadn't seen any of this prior to my asking my hubby for it after discharge.)

From what the gal in medical records told me (she was the supervisor) they will get to the bottom of this matter so it does not happen again.  She also gave me the name and phone number of a person in the Emergency Room that I can follow-up with if I had any concerns.

Bucky

[paperdoll]

Hiya,

I went to the ER last week and she wouldn't give me a copy of my discharge papers.  She looked down and said she wasn't finished writing them out.

We left without them.



Thanks for all the education gang!
P.

[Bucky]

Paperdoll . . . . sorry for your ER trip.  If you still want a copy of your discharge papers the hospital should be able to get you a copy of them.  You will probably have to sign something requesting them.

I don't have the copy of my "discharge papers" with my name on them or all the information, but I DO have the whole packet of papers of everything that happened from the time I walked in the door to the time I was discharged.  I had to sign for these papers in the "record" department. 

Hope you're feeling better. 

Bucky

[Jag]

If I were in your position, I'd call the hippa hotline. That way you're not going to anyone who'd know it was you who called. If you go through the facility, you don't know if it would EVER be reported to the powers that be. If you get a lawyer, everyone's hackles will be up immediately. Trust me, all I did was consult an attorney about severe burn that happened on my forehead after a surgery... the doctor refused to tell me what it was from!

Turns out the lawyer's doctors said it was most likely an allergic reaction to the adhesive, but it was an electrical monitor and the burns were SO deep that it caused the whole top of my head to go numb, so we thought that it was a burn burn. That doctor who is the only neuro-otologist in the entire area refused to allow me back in his office to see any of the docs. I have been very upset because all I wanted was an answer that he wouldn't give me. It's just the knowledge that you got a lawyer and that's all it takes.

I think you'd be better off reporting it to the hotline... just my humble opinion...

Jag

[tuckerdog]

One of the reasons healthcare costs have increased dramatically is because of the HIPAA regulations.  All of the computer systems had to be upgraded to track any inquiry or reporting transaction so that an audit trail is available to show every time a person even looks at patient information.  The computer system will be able to show exactly who printed that report and sent it to you in error.  There is obviously a huge deficiency at that site.  Violations of the HIPAA law are subject to fines and even jail time.  In a case like this it seems like the site has a deficiency procedurally, with their training and their personnel.  You would be doing everyone a favor to report that clinic to HIPAA.  Accurate medical records are absolutely necessary if patients are to get effective treatment.

Tuckerdog

[Jag]

That's not exactly accurate. If medical records pulled a chart and made a copy of a report on a copier to send out to a patient, then there would be no paper trail as to who copied it or who sent it. HIPPA requires certain things, but it doesn't require medical records to be fully computerized, nor does it require computer systems that track who looks at or copies medical records.

In some a lot of facilities, it's still on the 'honor system' where the facility itself can be penalized for a breach if there isn't a record of who exactly made the error. I don't believe that this instance was a malicious intent, so the penalty could be as little as a 'plan of action' by the facility as to how they are going to change their processes to keep this from happening in the future. However, each breach should be reported so that the chances of it happening again are lessened.

Health care costs are driven by a number of things, including the number of uninsured people in the country, the cost of providing healthcare to those people, the cost of care in general (which changes each time there are new 'improvements' in technology, medications, etc), how sick in general the insured people are getting (people have increasing health care costs as obesity, lifespan, and non-compliance increases), and may other factors.

I was a little amazed during the time I spent working at an insurance company what the world looked like from the other side of the window. People are demanding more healthcare than ever before, the doctors and other medical professionals aren't doing a good job of explaining 'quality of life', and the insurance companies are always played to be the bad guys... but it's nurses and doctors on that side, too. 

It's a very complex system, with very complex issues. HIPPA was a consumer driven set of criteria set up to do one thing.. protecting the patient and that patient's right to privacy. Facilities have chosen to make adjustments above and beyond to track who 'touches' the info as much as possible, but it's not foolproof. If even a few 'mistakes' slide, then it's not ever going to do what it was meant to do. The amount of money to update systems as the facilities have seen fit is a drop in the bucket compared to the other factors driving healthcare costs.