Medical Records Issue

[eslaptyback]

I had a question about false information/statements by a doctor on my medical records.

My treatment was discontinued and I was dismissed from a medical practice focusing on pain management. I requested that a copy of my records be sent to another MD so I could continue my treatment. The new MD gave me a copy of those records that were sent to him for reference.

On one of the records for my final visit (and subsequent dismissal....) to the previous MD's office it states in the objective section of the notes that the MD gave me an assessment/physical, one of the notes says:

"There is tenderness to palpation in the right lumbar area"

Now I find that odd when I NEVER saw the MD in the first place nor was I ever given a physical. A nurse came in and just took my vitals and that was it. The only other person I saw was a nurse practitioner who came in to tell me that they were dismissing me and discontinuing treatment.

On another record for the same visit there is a section titled "ATTESTATION STATEMENT" where it says "I attest that I was physically present for key portions of the history, physical, assessment and plan" signed by the MD.

Once again I find this odd because the MD was NEVER in the room with me. I had asked the nurse practitioner to speak with the MD, she left the room for a few minutes then came back in and stated "The Dr cannot see you now because he is busy with patients". I stated that I was a patient and had an appointment scheduled to see him that day, she stated that he could not see me.

Some of my other records also state that the MD did physicals on me while I was NEVER touched by ANYONE.....

Isn't this basically falsifying information on my medical records?

 

[mightymoose]

It's possible they have someone else's info in your record... have you brought the discrepancies to their attention yet? That would be the first thing to do.

 

[eslaptyback]

No these are my medical records.

See I know a little bit about this as I was a Paramedic for roughly 10 years. After EVERY call you did on the ambulance you had to fill out what is called a trip sheet where you write out the details of the call and ALL pertinent infomation about the call/patient (history, physical, assessment details, cheif complaint, vitals, etc). This record is attached to their medical records and is also a legal document. If you wrote in that report that you did something and it was not done (like stating that you took the patients blood pressure) their could be SERIOUS ramifications. I have been called to court as a witness on several occasions for what was and was not written on these trip sheets that happened on a call/with a patient.

I worked for a private transport service that transported patients to and from Dialysis clinics all day long. The owners of the company wanted us to ALWAYS write on these trip sheets that we carried the patient to the stretcher even if we did not. They wanted us to do that so they can charge more for the services rendered to the patients insurance (if the patient walked to the stretcher they got paid MUCH less for the transport.....). Now quite a few of us REFUSED to do it and they tried to pressure us into doing it. Eventually they fired someone for not doing it as an example to the rest of us, shortly thereafter they were investigated and found guilty of Medicare/Insurance Fraud.......

 

[mightymoose]

Well if that is what you were getting at then you could report the matter for investigation of insurance fraud.
Still, the first place to start asking questions about it is the doctor's office.