1. < Gynecologic Cancers
Profile picture for lilypearl

Erroneous Information in Medical Record

Posted by lilypearl @lilypearl, Aug 9 1:16pm

Two doctors (a resident and a supervisor) did a presurgical optimization video visit with me in May 2025.
When I got the interview report from them, they had signed off with the wrong information about me.
I'm jumping through hoops now trying to get my hospital health record (legal medical record) corrected.
Faxed in my request to amend my record and received a denial letter. The hospital health information department would NOT APPROVE my request to correct MY medical record.
I was specific with my reasons and asked if I needed to get an attorney to help me get my health information corrected.
Still waiting to hear about my disagreement.
Anyone have a similar issue with their health information being wrong?
The hospital system I'm dealing with is huge and often buys up other "smaller" healthcare systems.
Not good energy for a recuperating surgery patient.
Patient advocate insight is appreciated.
Thank you.

Interested in more discussions like this? Go to the Gynecologic Cancers Support Group.

Profile picture for lilypearl
lilypearl | @lilypearl | Aug 10 4:30pm

ASA III rating is from the website American Society of Anesthesiologists.

REPLY
Profile picture for Helen, Volunteer Mentor
Mentor
Helen, Volunteer Mentor | @naturegirl5 | Aug 10 7:37pm
In reply to @lilypearl "My age. They wrote eight years younger than I am. They classified me an anesthesia risk..." + (show)
Profile picture for lilypearl @lilypearl

My age.
They wrote eight years younger than I am.
They classified me an anesthesia risk of ASA III, someone with severe systemic disease, which I do not have.
None of this applies to me:
ASA III Substantive functional limitations; One or more moderate to severe diseases. Poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, history (>3 months) of MI, CVA, TIA, or CAD/stents.

Jump to this post

@lilypearl Yes, these are serious errors in your medical record. Thank you for sharing. The medical provider who wrote this report may have confused with another patient but this is never OK. I hope you will pursue getting your medical record amended. Will you come back and let me know what you do and what results you get?

REPLY
Profile picture for lathomasmd
lathomasmd | @lathomasmd | Aug 11 2:23pm
In reply to @sbt19 "In my last visit with my pcp in July, she used an “AI scribe” to take..." + (show)
Profile picture for sbt19 @sbt19

In my last visit with my pcp in July, she used an “AI scribe” to take notes during my visit. It was the most accurate and complete recording of what I said and what she said. She was also able to have a conversation with me face to face without having her face in a laptop. The only inaccurate information was my weight which was input by the medical assistant who transposed numbers. I am very leery of all things AI, but this is one area where it seems to work.

Jump to this post

“AI Scribe” sounds like a winner for both patients and doctors. It is likely more accurate, doesn’t forget info or mix patients up, and would certainly help patients who are uncomfortable with human scribes.

REPLY
Profile picture for annewoodmayo
annewoodmayo | @annewoodmayo | Aug 11 3:20pm
In reply to @lathomasmd "The medical record is a legal document. Once a note is signed by the doctor, it..." + (show)
Profile picture for lathomasmd @lathomasmd

The medical record is a legal document. Once a note is signed by the doctor, it cannot be changed. When we started using electronic medical records, the inability to change a note after signing it was built into the software. But it can be amended, as described above.
I agree that inaccurate doctors’ notes are a problem, and too many doctors just don’t care. In my own practice, I have mixed up patients and I have forgotten information when writing a note at the end of the day. A solution that helped my note-taking accuracy was to type as much as I could while the patient was talking. And to try to make it less rude, I explain to the patient that this helps me write more accurately. I also use a laptop, so I can face the patient.
But even so, doctors’ notes are completely one-sided. Miscommunication and misunderstanding happen. Yet legally, doctors’ notes carry more weight than what a patient might say later. Not fair, but that’s the way it is.
Probably the best way to have a say in the accuracy of your own medical records is to read the note as soon as you can, and request an amendment (when necessary) as soon as possible. Sooner amendment requests carry more weight than later ones. And if you do this in the portal, it will be legally time-stamped and legally part of the medical record.
But the best solution to all this is to get doctors to really care about accuracy.

Jump to this post

Doc,
Thank you for using your valuable time to reply here. It's great to hear from the other side of the desk. 🙂

A couple of my docs have hired a "scribe" who is present during the exam and types the doc's notes as the examination proceeds. A little weird to have another party in the exam room. Before the end of the appointment, the doc reads what the scribe has typed and verifies with me.
Might be expensive to hire a scribe, but probably saves time and aggravation, and ensures an accurate record.

Thank you, again! You sound like a caring doc. Bless you!

REPLY
1 reply
Profile picture for annewoodmayo
annewoodmayo | @annewoodmayo | Aug 11 3:29pm
In reply to @annewoodmayo "Doc, Thank you for using your valuable time to reply here. It's great to hear from..." + (show)
Profile picture for annewoodmayo @annewoodmayo

Doc,
Thank you for using your valuable time to reply here. It's great to hear from the other side of the desk. 🙂

A couple of my docs have hired a "scribe" who is present during the exam and types the doc's notes as the examination proceeds. A little weird to have another party in the exam room. Before the end of the appointment, the doc reads what the scribe has typed and verifies with me.
Might be expensive to hire a scribe, but probably saves time and aggravation, and ensures an accurate record.

Thank you, again! You sound like a caring doc. Bless you!

Jump to this post

Oops, sorry to repeat the scribe topic.
AI scribe-- I'd rather a human. Either human or AI, I think the key is for the doctor to review with the patient before the appointment is over.

REPLY
Profile picture for annewoodmayo
annewoodmayo | @annewoodmayo | Aug 11 3:38pm

Basic records, like weight, are important, too.
My insurance company denied a lung cancer screening. In a letter, they told me that I had symptoms of cancer. In a letter! My pulmonologist was furious. I did not have any symptoms of cancer.
Looking over my records, the only possible symptom of cancer was "unexplained weight loss," which was inaccurate because my weight had been recorded inaccurately.
It appeared that I had lost 20 lbs in one month, not 9 months.

REPLY
Profile picture for annewoodmayo
annewoodmayo | @annewoodmayo | Aug 11 4:01pm

To Medicare patients and everyone who pays for Medicare:
Some insurance companies are using Artificial Intelligence to go through our medical records (Medicare patients) in order to "beef up" our level of sickness. Medicare Advantage plans get paid more money if the patient is sicker/needs more care/needs more screenings etc.

When I read about this, I did not believe it.
Then, when I needed to check my patient portal for something else, I saw multiple new diagnoses! I called the doctor's office, and the office manager said that she had received numerous calls from patients about the same issue. And she mentioned the insurance company's use of AI to comb through my records in order to include as many health problems as possible.

For example, I had medical test A. It confirmed disease X. The insurance code for test A also includes diseases Y and Z. Diseases Y and Z were added to my medical record by the insurance company, without notification to me or to my doctor. I happened to find them in my patient portal records.

Whenever I can, I get a print out of the doctor's visit BEFORE I leave the office that day, even if I have to wait for it. Then I read it before I leave the office.

Things have gotten out- of- hand bad.

REPLY
Profile picture for sbt19
sbt19 | @sbt19 | Aug 12 7:07pm
In reply to @lilypearl "What does the AI scribe look like? Is there another person in the room with you..." + (show)
Profile picture for lilypearl @lilypearl

What does the AI scribe look like?
Is there another person in the room with you and your PCP that handles the AI device?

Jump to this post

The aI scribe is artificial intelligence computer program that listens (records) what is being said and then artesian a summary of the visit. It’s just the doctor and you and the computer in the exam room. The doctor should ask you if you agree to using the AI scribe.

REPLY
View MoreView Less
Please sign in or register to post a reply.