Worthwhile to correct doctor's visit notes?

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Seasonal
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Worthwhile to correct doctor's visit notes?

Post by Seasonal »

The last few times I've seen a doctor, the office had a patient portal that allowed me to see the doctor's notes of the visit. Every time there have been significant inaccuracies in the notes. Sometimes this results in billing problems, sometimes not.

For example, I had an appointment this morning and the doctor's notes included an examination that did not occur and descriptions of advice that was not given, plus a note that I gave written consent to a minor procedure after being advised of risks (it was oral consent and I was not advised of risks). A prior telemedicine visit with another doctor in the same practice included a description of an examination that did not happen (and likely couldn't happen remotely). Today's notes for that non-existent examination were word-for-word the same as the telemedicine notes. I presume doctors have canned responses and just push cut and paste, given time pressures, etc.

In today's case, I spoke to the nurse who was there (who oddly did not push back on anything) and followed up in writing. I presume it's a good idea to correct the record as soon as possible, but I'm wondering if there's anything else I should be doing.

EDIT: these are a series of different doctors, not the same one multiple times.
Last edited by Seasonal on Sat Aug 15, 2020 8:30 am, edited 1 time in total.
z91
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Re: Worthwhile to correct doctor's visit notes?

Post by z91 »

Yes, get it corrected. If you ever do a life insurance quote, they'll want all doctor's notes. If anything there is incorrect, especially if it could change your rate, get it fixed, otherwise it'll be their word versus yours, and the doctor will likely not remember, so the writing stays.
DJZ
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Re: Worthwhile to correct doctor's visit notes?

Post by DJZ »

Oh yes get it corrected. It could make a difference in billing, but also, notes do generally have a default template and the doctor will want to know that the template (s)he’s using for telemedicine has a physical exam in it; it’s likely that all of his/her telemedicine notes are incorrect. There could be legal consequences for the doctor if not corrected.
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Seasonal
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Re: Worthwhile to correct doctor's visit notes?

Post by Seasonal »

DJZ wrote: Fri Aug 14, 2020 4:48 pm Oh yes get it corrected. It could make a difference in billing, but also, notes do generally have a default template and the doctor will want to know that the template (s)he’s using for telemedicine has a physical exam in it; it’s likely that all of his/her telemedicine notes are incorrect. There could be legal consequences for the doctor if not corrected.
FWIW, doctor 1 was telemedicine. The notes include that it was telemedicine. The office billed the insurance company for an office visit.

Doctor 2 was an in person visit. His notes had a definite template feel to them. I'm hoping he just accidentally hit a few extra buttons.
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Seasonal
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Re: Worthwhile to correct doctor's visit notes?

Post by Seasonal »

z91 wrote: Fri Aug 14, 2020 4:41 pm Yes, get it corrected. If you ever do a life insurance quote, they'll want all doctor's notes. If anything there is incorrect, especially if it could change your rate, get it fixed, otherwise it'll be their word versus yours, and the doctor will likely not remember, so the writing stays.
It would still seem to be the doctor's word versus mine, but I'm hoping pointing it out on the same day will lead to a correction.

I have no intention of getting life insurance, although I can see the importance for someone who might.
Balefire
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Re: Worthwhile to correct doctor's visit notes?

Post by Balefire »

Pick a different doctor if it is a repeat occurrence.
That is poor form and arguably unethical.
NewMoneyMustBeSmart
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Re: Worthwhile to correct doctor's visit notes?

Post by NewMoneyMustBeSmart »

z91 wrote: Fri Aug 14, 2020 4:41 pm Yes, get it corrected. If you ever do a life insurance quote, they'll want all doctor's notes. If anything there is incorrect, especially if it could change your rate, get it fixed, otherwise it'll be their word versus yours, and the doctor will likely not remember, so the writing stays.
Agree! When I was a young man, I asked my doctor about the risks of cocaine. Somehow he took this as me using cocaine (which I hadn't!). His notes in the file eliminated my ability to get private health insurance.

In general, for me, it makes sense to correct actual knowledge of errors.
-- | Few are those who see with their own eyes and feel with their own hearts - Einstein
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samsoes
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Re: Worthwhile to correct doctor's visit notes?

Post by samsoes »

NewMoneyMustBeSmart wrote: Fri Aug 14, 2020 6:46 pm Agree! When I was a young man, I asked my doctor about the risks of cocaine. Somehow he took this as me using cocaine (which I hadn't!). His notes in the file eliminated my ability to get private health insurance.
Now that's frightening! :shock:
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LilyFleur
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Re: Worthwhile to correct doctor's visit notes?

Post by LilyFleur »

I have never found an error on my doctor's notes. The notes are very individual to me and not from a template.

When I am in the office, they are typing into the computer throughout the visit, logging as we go along.

I wouldn't feel comfortable at all with that type of inaccuracy in my own medical records.
meebers
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Re: Worthwhile to correct doctor's visit notes?

Post by meebers »

I went in for a [LEFT] knee total replacement. About a month later I asked for my records to review etc. No one, my PC doctor, his staff even me had noticed an error on the follow up radiology report except my wife. The radiologist report was about 4 paragraphs long and he kept referencing my [RIGHT] knee. Went to the hospital radiology department and asked for a print out view of my knee, on the ex ray was a giant [L] signifying LEFT. XXX was hitting the fan about that time. They are not allowed to correct the record, but wrote an addendum stating otherwise. Maybe the guy was looking at a right knee of someone else??? and there was a record snafu. Still wondering ...knee works great!

Went in for a 6 month follow up visit with the surgeon and as he was reading his notes, he said I can't believe I wrote this, its so wrong and nowhere up to date with what we are doing now. :(
psy1
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Re: Worthwhile to correct doctor's visit notes?

Post by psy1 »

It is good to correct the notes and make sure that the doctor is not fraudulantly upcoding the visit to bill at a higher level than the service performed. However, keep in mind that electronic health records are not designed for the physician, they are designed for billing, liability minimization, statisticians, and governmental/insurance overlords.

Where I last worked, a 15 minute hospital encounter might generate a 17 page note. I am not exaggerating. Some electronic health records are good enough, some are awful. The awful ones make it difficult and time consuming for the physician to generate a unique note for a visit. That is why you see so much boilerplate. A normal exam translates to multiple pages of text instead of a dictation from the old days that might say "physical exam within normal limits and unchanged since last visit." Instead, you will get the item by item detail of everything that is included in a physical exam because the insurance companies will not pay unless each item is specifically documented.

Also, billing for simple office visits is a PhD project. The requirements are multiple elements from multiple spheres which allows the insurance companies and government to contest every bill if they want and there is enough wiggle room in the definitions that "fraud" can easily be manufactured at will. Of course, that also allows the scammer types to routinely attempt to upcode visits to maximize re-imbursement. In general, routine office visits should be the "middle code" of billing and not the highest level.

It is generally easier to request a clarifying addendum to the note rather than a change to the note itself. It is also helpful to state precisely what you want the addendum to convey.
carolinaman
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Re: Worthwhile to correct doctor's visit notes?

Post by carolinaman »

meebers wrote: Fri Aug 14, 2020 8:43 pm I went in for a [LEFT] knee total replacement. About a month later I asked for my records to review etc. No one, my PC doctor, his staff even me had noticed an error on the follow up radiology report except my wife. The radiologist report was about 4 paragraphs long and he kept referencing my [RIGHT] knee. Went to the hospital radiology department and asked for a print out view of my knee, on the ex ray was a giant [L] signifying LEFT. XXX was hitting the fan about that time. They are not allowed to correct the record, but wrote an addendum stating otherwise. Maybe the guy was looking at a right knee of someone else??? and there was a record snafu. Still wondering ...knee works great!

Went in for a 6 month follow up visit with the surgeon and as he was reading his notes, he said I can't believe I wrote this, its so wrong and nowhere up to date with what we are doing now. :(
Wow! It is a good thing he did not get knees mixed up doing the replacement. Scary
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msi
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Re: Worthwhile to correct doctor's visit notes?

Post by msi »

Seasonal wrote: Fri Aug 14, 2020 4:38 pm The last few times I've seen a doctor, the office had a patient portal that allowed me to see the doctor's notes of the visit. Every time there have been significant inaccuracies in the notes. Sometimes this results in billing problems, sometimes not.

For example, I had an appointment this morning and the doctor's notes included an examination that did not occur and descriptions of advice that was not given, plus a note that I gave written consent to a minor procedure after being advised of risks (it was oral consent and I was not advised of risks). A prior telemedicine visit with another doctor in the same practice included a description of an examination that did not happen (and likely couldn't happen remotely). Today's notes for that non-existent examination were word-for-word the same as the telemedicine notes. I presume doctors have canned responses and just push cut and paste, given time pressures, etc.

In today's case, I spoke to the nurse who was there (who oddly did not push back on anything) and followed up in writing. I presume it's a good idea to correct the record as soon as possible, but I'm wondering if there's anything else I should be doing.
I would find another doctor. Never experienced that with mine.
squirm
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Re: Worthwhile to correct doctor's visit notes?

Post by squirm »

My specialist is in prison for scamming the system.
JPM
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Re: Worthwhile to correct doctor's visit notes?

Post by JPM »

The copy and paste feature of the note writing systems on the current electronic medical records systems is open to abuse/error.

The doctor's note generally has 3 sections he/she probably always fills out at your clinic visit and may bring forward with the copy-and paste function from your last visit; The History of Present Illness, the Review of Systems, and the Physical exam.

Then there are other sections; the recording of the review of lab reports or imaging data which usually follows the section for the physical exam. After that there is an "Assessment and Plan" section. These latter sections are generally more variable from visit to visit and so less subject to the copy-and-paste function.

The History of Present Illness is usually an update of what has happened since your last visit that may be relevant to the present visit or simply a stating of the acute problem and its characteristics. Doctors don't usually copy and paste this section but some may do so on occasion when the responses to the usual brief litany of standard key questions (e.g "have you had any chest pain, faintness, or shortness of breath with activity?")receives the usual negative answers.

The Review of Systems is a series of questions routinely asked at every visit and sometimes includes an embellishment or restatement some or all of the History of Present illness with related material that may be brought forward in the next note and may serve to remind the doctor to follow it up on the next visit. The problems in the copy-and-paste function usually lie in the Review of Systems or the Physical Exam sections because many of the remarks in those sections remain accurate and do not change over time. If the whites of your eyes (conjunctivae) are normal and you have a droopy left eyelid, those features of the physical exam seldom change and so seldom need to be edited. Using the copy-and-paste functions allows the doctor to spend less time on the charting of the visit (and more time discussing what is important to you) but also may be an occasion of error if the section is not properly edited in accord with what has transpired at the current visit. If for example the doctor looked in your ears last visit but not on this visit, then the pasted copy should be edited to reflect that change in procedure.

Another problem that occurs in contemporary practice is for the charting to be done hours after the visit when memory can become confused as to which patient said what and what the specific exam findings were in a specific patient. Because charting in the electronic record is so time-consuming now, many (most?) doctors do not complete the charting of the visit by the end of the visit and have to recall it later and the later it is recalled, the less accurately it is likely to be recalled.

In short, yes inaccurate charting is an entirely appropriate thing to bring up with the doctor. One of the reasons doctors like patients to be able to view the notes is so that they know and understand what the doctors are perceiving, thinking, and planning on their behalf. So it is important that the perception, thought, and plan be recored accurately. Sometimes patients will say something like "You know doctor, I saw what you said about me and I changed my mind and decided to go ahead and (have that colonoscopy, stress test, quit smoking, or start exercising, etc) after all. " The doctor may be chagrinned if you point out the error, but you are doing him/her a favor. It's good for the doctor to know someone is watching in addition to the usual medical oversight function.
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BolderBoy
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Re: Worthwhile to correct doctor's visit notes?

Post by BolderBoy »

Yes, try to get it fixed.

Then find another medical practice as your provider.
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meebers
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Re: Worthwhile to correct doctor's visit notes?

Post by meebers »

carolinaman wrote: Sat Aug 15, 2020 7:12 am
meebers wrote: Fri Aug 14, 2020 8:43 pm I went in for a [LEFT] knee total replacement. About a month later I asked for my records to review etc. No one, my PC doctor, his staff even me had noticed an error on the follow up radiology report except my wife. The radiologist report was about 4 paragraphs long and he kept referencing my [RIGHT] knee. Went to the hospital radiology department and asked for a print out view of my knee, on the ex ray was a giant [L] signifying LEFT. XXX was hitting the fan about that time. They are not allowed to correct the record, but wrote an addendum stating otherwise. Maybe the guy was looking at a right knee of someone else??? and there was a record snafu. Still wondering ...knee works great!

Went in for a 6 month follow up visit with the surgeon and as he was reading his notes, he said I can't believe I wrote this, its so wrong and nowhere up to date with what we are doing now. :(
Wow! It is a good thing he did not get knees mixed up doing the replacement. Scary
That one was covered correctly. First, 1 hour before surgery, @ 5am asked me which knee, told him left. He immediately took a black magic marker? and drew a cut line on my left knee and made me initial it. Asked for verification from my wife and a surgical nurse as she was looking at my records. Told the surgeon that I would "grade" him on his ability to stay on the line. He is a remarkable guy, at 10:30 pm that night, he came to my hospital bed to check on me and asked how I was doing. :beer
meebers
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Re: Worthwhile to correct doctor's visit notes?

Post by meebers »

meebers wrote: Tue Aug 18, 2020 7:18 pm
carolinaman wrote: Sat Aug 15, 2020 7:12 am
meebers wrote: Fri Aug 14, 2020 8:43 pm I went in for a [LEFT] knee total replacement. About a month later I asked for my records to review etc. No one, my PC doctor, his staff even me had noticed an error on the follow up radiology report except my wife. The radiologist report was about 4 paragraphs long and he kept referencing my [RIGHT] knee. Went to the hospital radiology department and asked for a print out view of my knee, on the ex ray was a giant [L] signifying LEFT. XXX was hitting the fan about that time. They are not allowed to correct the record, but wrote an addendum stating otherwise. Maybe the guy was looking at a right knee of someone else??? and there was a record snafu. Still wondering ...knee works great!

Went in for a 6 month follow up visit with the surgeon and as he was reading his notes, he said I can't believe I wrote this, its so wrong and nowhere up to date with what we are doing now. :(
Wow! It is a good thing he did not get knees mixed up doing the replacement. Scary
That one was covered correctly. First, 1 hour before surgery, @ 5am asked me which knee, told him left. He immediately took a black magic marker? and drew a cut line on my left knee and made me initial it. Asked for verification from my wife and a surgical nurse as she was looking at my records. Told the surgeon that I would "grade" him on his ability to stay on the line. He is a remarkable guy, at 10:30 pm that night, he came to my hospital bed to check on me and asked how I was doing. :beer

My wife had her knee done 6 months earlier, she had to spend 4 days in the hospital and her surgeon was caught fraudulently over prescribing equipment and was terminated due to him receiving "kick backs"
Kennedy
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Re: Worthwhile to correct doctor's visit notes?

Post by Kennedy »

It's not uncommon for a doctor to use a scribe for charting. Scribes generally train for about a month before being cut loose. Scribes are in the room during the exam or tele-health appointment. Their job is to listen to what's happening and then input the information into the electronic health record in real time. You could only imagine how accurate the notes are when the scribe is the one typing the note. Doctors are busy and, unfortunately, don't always review the note for accuracy. (Some do, but many don't.)

Of course, there are great scribes, but many are in their early 20s without any previous medical experience and in the field for only a year or less before moving on to apply to medical school.

I once noted that my chart indicated I weighed 100 more pounds than I actually did (217 v 117 pounds). I tried not to take it personally.
carolinaman
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Re: Worthwhile to correct doctor's visit notes?

Post by carolinaman »

I have had access to doctor's notes for years. Occasionally, there is an error in their notes. So far none of these have been material and I have ignored them. If I consider it a material error, i.e. affecting billing, prognosis or treatment, then I would definitely bring it to their attention and ask for a correction or update.
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Seasonal
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Re: Worthwhile to correct doctor's visit notes?

Post by Seasonal »

Kennedy wrote: Tue Aug 18, 2020 7:43 pm It's not uncommon for a doctor to use a scribe for charting. Scribes generally train for about a month before being cut loose. Scribes are in the room during the exam or tele-health appointment. Their job is to listen to what's happening and then input the information into the electronic health record in real time. You could only imagine how accurate the notes are when the scribe is the one typing the note. Doctors are busy and, unfortunately, don't always review the note for accuracy. (Some do, but many don't.)

Of course, there are great scribes, but many are in their early 20s without any previous medical experience and in the field for only a year or less before moving on to apply to medical school.

I once noted that my chart indicated I weighed 100 more pounds than I actually did (217 v 117 pounds). I tried not to take it personally.
That the notes were prepared by a scribe rather than the doctor sounds likely. There was a medical assistant with an ipad in the room who asked me questions before the doctor came in and dealt with post-visit issues after he left. She did more medical things than purely taking notes, but I don't know her level of training. I talked to her later in the day and her side of the conversation makes more sense than it did at the time if she was the one who prepared the notes.
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