Records

[SkyBlue4]

So I was recently called in to see my GI doctor to discuss treatment for Gastritis which was found during my endoscopy. (I originally went to see him after a positive Celiac test that was run by my endocrinologist).

 

My GI doctor started off this second office appt by saying that the gastritis is so severe that he is surprised I don't have any abdominal pain with it. I assured him (once again) that I have no abdominal pain at all. After he reviewed medication options for the gastritis, he said he wanted to rule out H.Pylori as the cause so he would order blood work for that. That was it and I was sent on my way.

 

That was last week and now this week I received a copy of my medical records from his office (I always order copies of my records from specialists or any tests performed). I am floored to see what appears to be fabricated information in my notes. For example, listed as my chief complaint at the top of all his notes is- Abdominal Pain. Now perhaps he was just trying to justify the endoscopy for insurance? There is more... He told me he would perform 4 biopsies of the small intestine but I only see two total biopsies received at the lab and one of the two was from my stomach to test for H.pylori (why run the blood test for it then?). And apparently, I must have blacked out during our appts b/c during that time he counseled me on probiotic use, referred me to a nutritionist for the gluten-free diet and at our last appt.- discussed at length the diet restrictions for the Gastritis. None of this happened. 

 

There are many more discrepancies in his notes but you get the picture. I have seen mistakes made in other doctor's notes like mixing up who had what in family history. That's an honest mistake and not a huge deal. But the notes from this doctor are something else and have left me angry...which is probably not at all good for my gastritis.   

 

 

[GF Lover]

Hi SkyBlue

 

That is unreal.  It's like there was a completely different patient there.  I would call the office Nurse right away and confront her instead of the Doctor directly.  That gives him the out of saying "those are the notes to tell you on your next visit" or some idiot excuse, but it also lets him know that you get every copy and he needs to step up his game.  The other option is to get out your can of Whip Ass and send him to his ER. 

 

Good Luck with this one.

 

Colleen

[powerofpositivethinking]

ugh that is definitely upsetting    In regards to him writing abdominal pain on your records, it very well could have been to justify the procedure to the insurance company.  I'm pretty sure on all blood work from the GI I go to, he will continue to put the reason for the tests as constipation because that was one of my big complaints.  However it was one of my actual complaints and not something he made up...

 

 

 

 

That was last week and now this week I received a copy of my medical records from his office (I always order copies of my records from specialists or any tests performed). I am floored to see what appears to be fabricated information in my notes. For example, listed as my chief complaint at the top of all his notes is- Abdominal Pain. Now perhaps he was just trying to justify the endoscopy for insurance?