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Medical notes are largely fiction IME. You should request all your medical records from any doctor you have seen and start demanding they correct them. You will be shocked at the lies they tell about you. You will be even more shocked down the road when you find out how these lies can hurt you.
In (the UK at least) your medical notes follow you as you sign on with a new GP (General Practitioner - first point of medical contact for anything non-urgent). Now knew this theoretically happened, but was quite bemused to see it happen in practice. I rescued a rat from the silken-jaws of my pseudo-homicidal cat, and the ungrateful rodent bit through half of my finger - I thought it would be sensible to have a check…
That's amazing. I guess, in the US, we only started tracking patients recently. I had to call and have my old records faxed from my old GP in Texas to one in New Jersey, and then again from that GP to my NEWER one in New York. Earliest record was from when I was 7, since neither my mother or I remember who my pediatrician was before then.
You have everything from Psychology/Psychiatry notes to overdose records that many health staff can pull up from almost any computer.
EDIT: Remember many jobs disqualify you from the job if you have any past psychiatric treatment. Even if you are in your 40s Psych drugs at 13 are a disqualifier. "Paying cash" is what some doctors have resorted to. http://www.idealmedicalcare.org/75-med-students-antidepressa...
Earlier quoted context omitted.
In the US you're legally entitled to your medical records too but every time I've done it the response is always defensive, ie "why do you need them", "send me the doctors information and I'll fax it to them myself".
At Kaiser, you just have to walk into any member services office and request. It doesn't happen right then, but I believe in a few days you get a thumb drive with all of your records on them. However, the law allows the doctors to redact certain portions in your copy that they feel could be harmful to you.
Like what?
Earlier quoted context omitted.
every time I've done it the response is always defensive, ie "why do you need them" I was asked this once after requesting mine. I flatly said "I don't", and waited. The person on the other end of the line was clearly thrown off by this, probably expecting something they could dish out a canned response to, hoping I'd give up. It was obvious from their voice they were scrambling for what to say to that. A bit of rigm…
Why would they be so hesitant? Surely it’s not that extra work for an office admin to pull something up and hit “print”.
Medicine seems like a technological wasteland. They put "notes" into text boxes and call it "using computers". I wish I had both CS/SE experience and Medical experience so that I could understand what keeps this field in the 1970s. I have suspicions.
In my experience, it's a combination of a couple of things. First off, the field is heavily regulated (in the US anyway) and the penalties for violating regulations like HIPAA are incredibly high. Second, the field is currently dominated by major players such as Epic, so its pretty important to be compatible with them, but they don't really have an incentive to open up their ecosystem since they have such a strangleh…
Epic also has an app store. You can write your own SMART on FHIR apps, then deploy them inside the EHR with full access to patient data.
Medical notes are largely fiction IME. You should request all your medical records from any doctor you have seen and start demanding they correct them. You will be shocked at the lies they tell about you. You will be even more shocked down the road when you find out how these lies can hurt you.
True story, I had a major illness in my late 20s. And apparently I have a high tolerance for pain, so the nurses and doctors repeatedly underestimated how much pain I was in. I can be in incredible pain and still hold it together and answer questions in a calm and rational manner. This made one doctor suspicious that I was faking the whole thing. So then I tried to adjust my behavior. I started deliberately giving more outward signs of the pain I was in. And then the another doctor accused me of exaggerating or being a hypochondriac.
I was not able to find a level of external performance that kept all of my doctors happy. If I was too restrained, then they had trouble believing I was really feeling the pain that I described with my words. But if I tried to act the pain I felt, then I was accused of being a hypochondriac.
I should add that most of my doctors were great. In my whole life, I've only had 2 negative experiences with a doctor, the two that I just mentioned.
Earlier quoted context omitted.
At Kaiser, you just have to walk into any member services office and request. It doesn't happen right then, but I believe in a few days you get a thumb drive with all of your records on them. However, the law allows the doctors to redact certain portions in your copy that they feel could be harmful to you.
> However, the law allows the doctors to redact certain portions in your copy that they feel could be harmful to you. Like what?
This EHR data problem is something I've pondered for a bit. One "simple" solution is to have departmental standardization of note format with thoughtful inclusion of what fields are typically pertinent. This doesn't solve the problem of care transitions but it might help standardize review in a hospital context. The other thing that I've been pondering is something resembling a formalized data structure and language…
http://ist.jefferson.edu/content/dam/ist/epic/SmartList.PNG
http://3.bp.blogspot.com/-13TVMTrcPkA/UPWKAB_rTGI/AAAAAAAABD...
This EHR data problem is something I've pondered for a bit. One "simple" solution is to have departmental standardization of note format with thoughtful inclusion of what fields are typically pertinent. This doesn't solve the problem of care transitions but it might help standardize review in a hospital context. The other thing that I've been pondering is something resembling a formalized data structure and language…
For care transitions the HL7 C-CDA 2.1 Continuity of Care Document (CCD) format works pretty well. Modern EHRs can export a summary of a patient's chart in that format. Some data may be lost in translation but usually it works fine. But there are often still technical obstacles to transporting a CCD from one provider to another.
There are existing formal code systems for notes: CPT, ICD-10-CM, RxNorm, CVX, SNOMED-CT, etc. Those are helpful for billing and analysis purposes, but they can't replace free form narrative text for most clinical use cases.
This EHR data problem is something I've pondered for a bit. One "simple" solution is to have departmental standardization of note format with thoughtful inclusion of what fields are typically pertinent. This doesn't solve the problem of care transitions but it might help standardize review in a hospital context. The other thing that I've been pondering is something resembling a formalized data structure and language…
I talked to some other physicians about this, and I learned that hospital departments use their standardized notes to include as much detail (i.e. bloat) as possible so that physicians can bill at higher tiers since billing is tied to the number of details included in the note.
[1] https://www.aafp.org/fpm/2003/0100/p29.html#fpm20030100p29-b...
