Fact Versus Fiction in Medical Records

As a lot of you know, I have been dealing with a foot wound that keeps getting progressively worse. The most frustrating part of this for me is dealing with doctors and trying to get medical records straightened out. I have started to write a couple times about the things that have happened since I last wrote on March 5th – every time I start to write, I start to cry. I am going to save that stuff for another day!

I sent for my last set of records from the Ohio Valley General Hospital Wound Care Center. Even though they are the ones that changed my appointment in December, they closed my file and started me as a new patient, yet again. The envelope came the other day and I was afraid to open it. I opened it this morning and let’s just say, there is a reason some of us should not own guns! I am apparently “problematic” because I chose to get the mistakes from the October records corrected. I have a five page letter with corrections this time but thought I would share one big thing here.

When I was at the wound center on February 7th, the doctor gave me a script to get a PICC line inserted and start on Vancomycin. With Vancomycin, they measure the levels in your blood weekly and adjust it up or down depending on the levels in your blood.

This was in my records for February 28th:

Ohio Valley General Hospital Wound Care Center, Dr. Peter Dickinson notes for Kelly Booth

This was the actual script that I was given on February 7th:

Ohio Valley General Hospital prescription written by Dr. Peter Dickinson for Kelly Booth

Obviously, my actual starting dose was more than what he “believed” my increase dose was.

I started the Rocpehin on Monday, February 25th and was at the wound center on Thursday, the 28th. I might not have gone to medical school, but that works out to four days on my fingers. I have counted four or five times and I keep coming up with four days not two.

I guess the “I believe” gets thrown in when he prefers not put actual facts in.  Really, what fun are actual facts in medical records?  Why would it be important how much Vancomycin I was on?

This is what I wrote in my letter to Ohio Valley General Hospital Wound Care Center:

I was started on a larger dose of Vancomycin than Dr. Dickinson seems to “believe.”

February 11, 2013, I was started on 1.5 GM Vancomycin once a day – a copy of the prescription signed by Dr. Dickinson for that first dose is attached to this letter;

February 16, 2013, I was started on 2000 MG (2 GM) Vancomycin once a day;

February 20, 2013, I was started on 1200 MG (1.2 GM) Vancomycin twice a day (a total of 2.4 GM per day) – that is the dose that caused the allergic reaction.

The facts are very different than what Dr. Dickinson “believes.” Perhaps if doctors like Dr. Dickinson stated actual facts in my medical records, I would not have to correct the errors and get labeled a “problematic” patient because I prefer accurate medical records over made up ones. My first dose of Vancomycin was larger than what Dr. Dickinson “believes” I was ultimately increased to – again, I have attached a copy of that prescription and would like that copy a permanent part of my medical records. The last increase before the allergic reaction was almost twice as much as what Dr. Dickinson “believes” it was. I always thought medical records were supposed to be factual, especially when it comes to things like prescription drugs that were signed off on by a doctor. As I stated above, Dr. Dickinson prefers fiction and I prefer non-fiction and only want actual facts in my medical records.

I am still trying to work thru a lot of “anger” over what happened to me and seeing garbage like this really does not help that. I went to the wound center at Ohio Valley General Hospital because I believed that was my best chance of healing my foot.  Instead, I am fighting for my life.  I certainly did not know that I would be dealing with fictional medical records and doctors writing what drug dosages they “believe” I am on and not the actual amounts that they wrote the prescription for.

Welcome to the world of fictional medicine!

 

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6 thoughts on “Fact Versus Fiction in Medical Records

  1. Perhaps you went to Ohio Valley because they are, medically speaking, the best to deal with your wound. But clearly they’ve lost ambition in you (“problematic??”) and you’ve lost confidence in them. At this point, I don’t see this “relationship” working and it’s time to move on. It’s not like they’re relieving physical pain in exchange for emotional pain — and you deserve relief on both fronts.

    • Thanks Scott! Actually, I did move on after they left me off antibiotics for 5 days. I did go there because I have my leg today after going there originally in 2006. It isn’t the same wound center it was!

  2. I can tell from the tone of the letter you wrote them that you are very angry. Which you have every right to be — if the doc didn’t remember what your dose was (and it IS easy to forget when you’re treating a lot of patients), then he COULD have looked it up in your chart. That’s the reason for the push for electronic records — no doc should ever make any decision or write any report without having the facts on hand.

    That said, I am far more worried about YOU than I am about those records. I will not bug you about those things that are making you want to cry, but I want you to know I CARE. I want to keep you around, and I would be VERY sad if anything happened to you. Please, when you’re angry, at least remember that there are people who DO love you!

    • Very angry Natalie and you only saw one small part of that 5-page letter! I understand it is easy to forget stuff but what is in my records should be actual facts. This was not a discussion with me about treatment options, this what he wrote in my records that would get sent to other hospitals so should be accurate.

      I want to stay around too but all the medical errors is making that pretty tough. This guy left me off antibiotics for 5 days and then put me on one that the bug I have is resistant to – that was also confirmed by an infecitous disease doctor. That is making this very tough to fight and dealing with crap like this is just wasting what energy I have!

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