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Erroneous Information in Medical Record

Gynecologic Cancers | Last Active: Aug 12 7:07pm | Replies (18)

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I always see bogus stuff in my records when I read notes on the portals. I think they make those notes later in the day and forget the details or mix up patient conversations. I often read that we discussed things we never discussed like standard things they should counsel patients about but didn’t. CYA on their part. Or is see “patient denies having symptom x” when I specifically stated I have symptom x. So annoying. Most is small stuff so I don’t battle it. Sometimes they just didn’t understand what I was explaining. Once did I go back about something so opposite of a major symptom I had that I called them up and said I wanted it changed. They didn’t remove the bogus info, but added a note about my call and what I said the correction is. I accepted that. Another time they logged that I received vaccines that day that I didn’t receive or even discuss and I had that corrected. And a third doctor had me listed as 6” shorter than I am so it made me sound fat with my weight. Do I look 5’ 3”? LOL Easy fix at next visit. My issues were with a cancer radiation center and private practice doctors not a hospital. I have let tons of small errors go. If it will make a difference in your care then pursue it, but if it’s insignificant let it go because you’ll see it a lot over the years. Good luck.

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Replies to "I always see bogus stuff in my records when I read notes on the portals. I..."

I've written up medical and legal records in my past careers so I'm a stickler for documenting the correct information.
Granted many of the transcriptionists have multiple cases in a day to transcribe.
My sister said my record reads like they have information for some other patient in my record.