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:

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

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!