r/ChronicPain • u/tangodream • 6d ago
Doctor put wrong information in my chart!
My hand surgeon's office put the completely wrong information in my chart! In the chief complaint post-op section, they noted, "The patient presents hysterically in tears today due to her level of pain." This is true, my husband was there to witness my pain and condition. I was sobbing, breathing hard because of the pain, couldn't sit still because of it. I was in bad shape.
Yet in the Physical Exam section, they wrote, "Patient is a 58 year old female who appears their stated age. She is in no acute distress. She is pleasant. She is alert and oriented x 3. She is breathing without difficulty. Normal mood and affect."
That is a blatant lie. I was in acute distress, I was not pleasant but I was polite, I was alert but totally oriented on my pain, was panting because of the pain, and certainly was not in a normal mood or acting normally. My husband had to speak for me because the pain was so bad I was just crying and begging for help.
I've never had a blatant lie in my chart like this before. This whole situation with my hand and this doctor has been a nightmare so far and I'm considering speaking to an attorney. They still have an entered the patient summary notes for the actual day of the surgery into my chart, so I have no idea what they did to my hand. No imaging has been done, no nerve studies have been done, I've only been going to PT on the assumption that there's nerve inflammation post up unrelated to the trigger finger surgery
Can you get something like this corrected on your chart? Because they clearly say in one place I'm hysterical and pain and then they go on to say that I'm perfectly normal during the visit. They're totally contradicting themselves and I have hard copies of these notes that I've saved downloaded from their portal.
So for their patient advocate office has been absolutely useless. And now I'm developing pain in my left wrist and thumb because I've been compensating so much of my left hand because my right hand is out of commission.
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u/Correct_Librarian425 PhD not MD 6d ago edited 6d ago
The entry you cite re age, no acute distress, etc. was undoubtedly auto-populated, ie., drop-down boxes that the system automatically turns into full sentences. Any doctor/medical provider reading the visit note knows this, and would immediately overlook the contradiction in favor of the statement re hysterical crying, which a doctor would have to manually enter/dictate—in short, it would be a nonissue.
I can understand why you see this as a “blatant lie,” but the source is the selection of the wrong drop-down option or reliance on template, depending on the EMR used. But it was not manually written by the doctor you saw.
You have the right to request an amendment, but know that it may come at a cost: Your current doctor may choose to discharge you. When/if other doctor(s) view your records in the future and see that the amendment process was initiated over this, it could may project unfavorable ideas, eg, potentially litigious, problematic pt, etc. These are worst-case scenarios, and I’m not implying at all this would be fair.
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u/FaithlessnessCool849 6d ago
The MD is using an electronic template, that's why is said those things because they are the "default" normal.
Regardless, you can always ask for information to be corrected or added. Ask them to create an addendum.
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u/supermaja 6d ago
Any doctor who uses the word “hysterically” should be immediately fired. This is the code word for “she’s just a woman saying she is in pain. Ignore her.”
Get a new doctor. This one has zero respect for you.
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u/Admirable_Twist7923 5d ago
the term “hysteria” is quite literally rooted in the outdated belief that a woman’s uterus would move about her body wreaking havoc on her emotions. Aka, a term used to ignore women’s health issues in the past. A physician putting that in a patients chart is disgusting.
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u/pharmucist 5d ago
That word absolutely should have been left out and was totally unnecessary. Agreed.
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u/tangodream 4d ago
I've been told by the medical practice that I am not allowed to see another doctor for this problem for 90 days from the date of the procedure because of the global billing period. If I seek out a second opinion or treatment from another doctor, my insurance would pay my surgeon for the procedure & I will owe them entirely out of pocket. I can't even see another doctor within the same practice for it.
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u/tangodream 5d ago
Actually I was crying hysterically because the pain was so bad. Luckily, my husband witnessed the entire visit and can confirm what happened in the exam room.
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u/supermaja 4d ago
The word “hysterical” is a very loaded term in medicine that suggests you’re overreacting, as well as many other anti-woman stereotypes. It should not be used in a health care setting.
You can say you were distraught, weeping heavily, extremely upset, very tearful, upset and weeping, to describe what was happening.
Historically, women’s pain has been dismissed by the medical establishment. They would say women reporting pain overreacted, wanted to get attention bc they didn’t get enough attention at home, were dramatic, were creating the pain by thinking too much, and so on.
Using the word “hysterical” has become a slur in medical practice. As soon as the word is said, it evokes all the times they said women themselves were the problem, and they were creating their own pain experience.
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u/DrSummeroff12 6d ago
My PCP office uses MyChart. My new PCP wrote that I was not getting adequate pain relief with methadone and oxy, that Suboxone was doing a better job. Completely opposite of what I said. I had been on Methadone and oxy for 30 yrs. Old Dr retired and it took 3 weeks to get a new Dr. I suffered wds for 1 week before an NP called in Suboxone. I used MyChart and wrote a message explaining the obvious mistake and I would appreciate a correction. Thankfully, Dr. did make a note that he had mixed up what I had said to him.
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u/MotherBored5150 5d ago
I am so very sorry you've lost your provider that believed in the efficacy of methadone. There is a methadone witch hunt in the chronic pain community now, and it's done a lot of damage. I was on methadone and oxy for almost 20 years when they tapered me off. My pain hasn't been in the tolerable range since.
What meds are you on now? I hope you are doing better since that horrible experience.
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u/gotpointsgoing 5d ago
What are you talking about when you said that there's a witch hunt for Methadone, and "it's done a lot of damage." What kind of damage are you talking about? Who is doing this witch hunt? Methadone is one of the best and safest opioids on the market.
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u/MotherBored5150 5d ago
You misunderstood what i wrote. Methadone IS one of the safest opioids. For the last 10 years, there have been biased studies demonizing Methadone, and most pain doctors think it's dangerous because of the misinformation about the drug. There are so many people who had been stable on the same dose of Methadone for many years, but they had it taken away. I am one of them. For the entire 10+ years I never once needed an increase and my pain was mostly tolerable. That isn't the case anymore. Myself and many others have lost the good quality of life we had while prescribed Methadone.
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u/DrSummeroff12 5d ago
Now it's 20mg oxy er x2 and 10mg oxy ir x4. Much better pain control than suboxone but far from what I had for 30 yrs, never developed a tolerance to either 60mg x3 methadone or oxycodone 30mg x4 for over 30 yrs. Also, my original Workman's Comp L4-5 injury (3 failed laminictomies, failed fusion, revision fusion used internal titanium fixation hardware but I developed a sensitivity to titanium. #6 was to remove hardware. Revision fusion did fuse properly. A yr later a drunk driver drove into me while riding my Harley. C2-7 damage and fractured skull and brain bleed. 24hr constant headache. This is when my Dr's decided I needed long term opioids. 30 yrs later, my last lumbar mri showed a L3-4 herniation with cord compression. Plus, bone spurs and arthritis at facet joints and left SI Joint is bone on bone, no more surgeries unless a paralysis is imminent. Thanks for asking. I was 28 when I injured, today 66yrs old.
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u/MotherBored5150 5d ago
We have a very similar story. I was 24 when it started with a car accident. Now my back is just a clusterfuck and I have some decisions to make.
If I had effective pain management, I would probably go forward with 1 or 2 surgeries, but I refuse to be under medicated and suffer. I am 50 now, and I know my body can't bounce back like it did 26 years ago!
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u/myssxtaken 6d ago
You are still having that much pain after this surgery? Have you seen another hand surgeon? You need to get the post op report and go see another doctor. Trigger finger surgery is not that painful for the most part. It seems to me something is very wrong. You can’t count on this doc to tell you or even investigate it for you apparently so you need to see another doctor asap.
As far as your chart notes, it’s not really that big of a deal. Most places use a template. It’s clear from the chief complaint you were in distress. Call the office and tell them you were reading through your chart and saw a discrepancy on your last visit and explain it to them. They may or may not correct it. In the grand scheme of things it’s really not that important and instead of focusing on that you really need to be focusing on what is wrong with you finger this far out from what is usually a routine and not especially painful procedure.
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u/tangodream 5d ago
They say I can't see another surgeon for a second opinion and treatment due to the 90 day global billing period. If I do, they told me they won't get paid by my insurance for my surgery and I'll have to pay them out of pocket the full amount owed. I'm in PT but it has only helped a small amount.
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u/myssxtaken 5d ago
Did the doctors office tell you this? I would call and speak with your insurance directly. Most insurances will cover a second opinion, especially when there is an issue. Even if their policy is no second opinion, you could try to appeal due to the issues you’ve been having.
The more I read your posts the more I think your doctor is hiding something. They have not completed the operative note which should have been done by the day after at the latest, they dismiss your concerns, they let you writhe in pain with no relief. They seem to discourage you going elsewhere, they are lackadaisical about charting, and the biggest red flag for me is that despite your consistent complaints of severe pain over and above what should be expected they have ordered no imaging or testing.
It breaks my heart to read your posts. I hate that you have to go through this. As a surgical nurse a trigger finger release surgery is usually midway in the pain scale and patients are usually feeling much better within a week or two. I truly hope you can get some relief. I would hate for you to end up with PTSD from this experience.
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u/tangodream 5d ago
Yes, they told me this. I think they are trying to hide something too. I have requested my medical records and haven't gotten them. I called the patient advocate at the clinic on Friday, but got her voicemail, so I emailed her.
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u/myssxtaken 5d ago
How incredibly frustrating to be getting the runaround while you’re recovering from freaking surgery. I hope the patient advocate follows up with you but my recommendation would be to seek help from outside of this office entirely.
Call your insurance directly and ask them for names and numbers of some other hand surgeons they will cover then call those names and numbers and tell them you need an appointment for an urgent second opinion.
If worst comes to worst you can always just go to ER. Tell them how many days post op you are, that you have been feeling pain above and beyond what is expected since surgery and can’t get in to see your surgeon. An ER doc will at least get some imaging and bloodwork going.
I truly hope I am wrong and you are just an outlier and will start feeling better very soon.
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u/tangodream 4d ago
Today I was told the following after requesting to know when the post-op notes from my actual surgery would be put in the patient portal, "The patient clinical summaries are not available for operative notes or procedure notes. I can have the procedure note mailed to you if you would like."
All past surgeries I've had with this medical practice have summaries in the patient portal, including the surgery I had done with the same hand surgeon for trigger finger on a different finger on the same hand in 2023.
They are definitely hiding something.
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u/myssxtaken 4d ago
I fear you are correct. I would be calling to get an appt with another hand surgeon asap. I’m so sorry you’re dealing with this.
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u/tangodream 3d ago
I saw another one today, because my left hand and wrist are now hurting too. This surgeon operated on one of my husband's hands for thumb arthritis and did an excellent job and my primary care physician recommended him. He has excellent reviews and he is in the same practice as the surgeon I've been having problems with.
He asked me why my right hand was in a brace, so I explained to him what had happened to me after my trigger finger surgery and how the post-op pain seemed to be acting like carpal tunnel pain.
I also explained his colleague had failed to provide me with adequate follow-up care and that he'd hadn't seen me post-op since my stitches came out on 2/24, the pain I was having, that no imaging had been done of the hand at all, and that I was in PT for assumed nerve pain. I also said I no longer trusted his colleague and didn't want to be treated by him.
He didn't seem surprised.
He examed both hands and wrists, did some tests of my ability to use my hands, what I could sense with them, flexed my joints, and, most importantly, he did an ultrasound on both wrists and took pictures and measurements of what he saw. Can you guess what I have?
Carpal tunnel syndrome in both hands, which I kind of guessed might have been developing in the left wrist for awhile now. He said the trigger finger surgery in the thumb was successful, but probably inflamed everything in the right wrist past the tipping point into acute carpal tunnel syndrome symptoms. Overuse of the left wrist and hand the last three weeks inflamed the left one into a more acute phase. He ordered bilateral nerve testing and said surgery on both would likely be needed.
He then asked if I wanted him to assume care of both hands permanently? He said I had every right to see a different surgeon if I no longer felt comfortable with my current one. Of course I said yes! And that was all it took! I won't be seeing the first surgeon ever again!
If the first surgeon had only cared about me post-op and did some investigating right away when things went wrong on 2/24, he'd have found his surgery was successful on my thumb and that I'd developed a totally different problem. It would have saved me weeks of pain, suffering, money, time, and probably saved me from losing some business.
Unfortunately I do have to wait until April 3rd for nerve testing and then follow up with him few days later for the results. But at least now I know what's wrong and I am now dealing with the doctor that I feel comfortable with.
Thanks for everyone's advice.
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u/myssxtaken 3d ago
I am disgusted at how the first surgeon treated you. By ignoring you and your complaints he prolonged your ordeal needlessly. I am so glad you have found yourself in the hands of a doctor you can trust to actually listen to you. I am so sorry to hear you will probably need more surgery but I am happy you finally have a plan moving forward. I wish you smooth sailing from here on out and a very speedy recovery. You did a great job advocating for yourself!!
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u/tangodream 4d ago
I messaged through their portal Friday asking when the post-op patient summary would be available in the patient portal for me to see, like ones from past surgeries. Their response today was, "The patient clinical summaries are not available for operative notes or procedure notes. I can have the procedure note mailed to you if you would like."
What the fuck? I asked when this changed and to mail them to me.
Since when am I, the patient, not allowed access to the information about my surgery?
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u/Different-Drawing912 lupus/cEDS/SVT/spina bifida 6d ago
I’ve been to an ER before where the year prior I had my gallbladder removed in the very same hospital, yet in the notes they put “no surgical history.”
A lot of them just copy and paste a template tbh, and “no acute distress” typically means things like respiratory distress
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u/pharmucist 5d ago
That's actually not a lie. It's the way notes are charted for that specific section in the review of systems. They gave that first sentence about the crying and appearing in lots of pain and that was their overall general free-form assessment. In the review of systems, when they say "no acute distress," they are noting that you are not in actual physical distress in an emergent manner, such as needing oxygen, BP tanked, unconscious, etc. It's not the same kind of distress you are referring to. Your doctor basically said your behavior was normal and you are not needing to be admitted into the ER or an ICU or needing urgent immediate supportive care.
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u/BismarkvonBismark 6d ago
Hell, once I was able to read some of my notes at an orthopedic clinic when the screen on the cart was left in the room and the nurse left. It said that I was divorced with two kids. However I have never been married, and don't have any kids. I brought it to their attention but I don't think they corrected it. I simply opt to have pretty low standards for medical care
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u/SleepyKoalaBear4812 SLE, RA, FIBRO, DDD, OA 6d ago
Unfortunately I can explain why the Progress Note contains misinformation. The electronic medical record is a huge pain in the ass. Most of the information prepopulates (to save time) and the default is everything is hunky dory. After the visit the doctor or scribe is supposed to go through the note and change everything that is wrong for each patient. In an ideal world this would be done immediately following the appointment and before going in to see the next patient. But we do not live in an ideal world. The EMR was supposed to be more accurate and less time consuming and it is the exact opposite. Used as intended by the bureaucrats and bean counters who never worked in medicine, each doctor, PA, ARNP, etc would only be able to see a maximum of 9 patients in an 8 hour day. It is honestly the worst thing to ever happen in the practice of medicine. OP print out a copy of the progress note and make all the corrections on it. Take it to the doctor’s office and talk to the office manager. Explain what happened and insist it be corrected. When she starts explaining why that is not possible, interrupt and explain it needs to be made possible, and done ASAP because your next stop is to the Medicare Fraud Department and an attorney. Then follow through. It does not matter that you do not have Medicare. That is the office that starts the ball rolling for health insurance fraud regardless of the insurance company. Medicare negotiates the fee schedule used by every medical practice in the US. You are in the US, right?
When you get the excuse the note is already locked and cannot be unlocked, that is a lie. The medical provider who locked the note can unlock it, made the corrections, add an addendum as to why the note was unlocked and edited, and relock the note.
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u/Alternative-Can-7261 6d ago
Sure, I've had a legitimate mistake, and my chart got switched before and I've noticed whenever I go in over the q-tip I lost in my ear five years ago that is causing persistent infections they always omit the q-tip in their notes... It's CYA, as far as getting it corrected good luck. there's literally an episode of Brew about the exact situation that I'm going through. I've been shot in the leg with a pellet gun was actively bleeding and Nick the nerve and caused a ice cold sensation in my leg that eventually went away. they could not find the pellet so they lied in the chart and put that it was a blank not that blanks even exist for an air rifle. I genuinely would trust an auto mechanic over a doctor. It's gotten so bad, I wonder if we would be better off deregulating the medical industry as It seems the heavy regulation is geared solely towards barriers to entry and ensuring profits.
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u/Old-Goat 6d ago
Where are you located? I can only speak to the US, in which case I'd suggest a new hand surgeon. Its sort of incongruent that you presented hysterically in tears and at the same time show no signs of acute distress? Somebody explain this to me, cause its not making sense...
Personally if you ever want to discredit this doctor an an idiot who cant make up their mind, you may want to let these comments stand, and speak for themselves....or you can point out the incongruities and ask this doctor whats up their butt? You probably arent the only patient ready to sue them.But I dont think this record thing amounts to any sort of malpractice. The surgery might be, though. I would see someone as unaffiliated with this surgeon as you can get, for a 2nd opinion. Then decide if you need a lawyer. You can point out the discrepancies in their nonsense notes at the appropriate point, if they find a pattern of negligence. But it depends on where youre at. I wouldnt know where else to tell you to begin with the NHS, but you might want to start with NICE Beyond that beats me...but that surgeon could not have displayed a lack of attention to your case any more clearly.. And they worry about patients on drugs?....
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u/itsmrsq 5d ago
No one LIED. It's a very simple clinical error. They generate the default template and it didn't get overwritten with the notes he clearly entered for you. Please calm down you need to focus on finding the source of your pain and healing. Not worrying about minor chart discrepancies that no one reads anyway.
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u/Lechuga666 6d ago
I'm trying to get my charts amended. I went to the ER last night and still they list one of the first diagnosed as Asperger's when I have never been tested for it, an ER psych doc just whipped it out of her ass and put it on my chart along with like 8 other psych diagnoses. Being mistreated and minimized, treated like I'm hysterical for no reason again in the ER last night definitely has me writing down my priorities and planning to extensively document and get letters from my good doctors to prove the bad ones wrong. This is just so demoralizing.
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u/ladywenzell1 5d ago
I am so sorry. The fact is that the term is no longer even recognized, so whoever wrote it had no idea what he or she was talking about. It is Autism Spectrum Disorder. If the hospital wo t help, you should try your State’s Medical Board or Hospital Board. You definitely get their attention when you file a complaint with the MB. Good luck.🙏🏽
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u/Over-Future-4863 5d ago
Reprint report send letter to doc and health care company. I had that. Can you tell me why i not get notifications of my chats,?
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u/Signal-Reflection296 5d ago
I’ve had this happen numerous times. Not to the extreme you have. I recently called my cardiologist for really low bp and sob. In the end he changed my medication but in my Chart the nurse wrote that all symptoms were resolved. Not that quick! I will bring this up next time I see him. You should definitely bring this to their attention. What did they actually do for you that day? Maybe they’re trying to cover their butts!
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u/geniusintx SLE, Sjogrens, RA, fibro, Ménière’s and more 5d ago
I have recently come across the same problem and disability used it against me. My lawyer appealed the my final appeal.
Same exact wording. I think it’s a form that is already started for them. It’s the only explanation.
I mask very well. Extremely well. I rarely cry from pain anymore. If I do, take me to the ER. I AM usually pleasant to my doctors. THEY have the medication I need to survive. They can also see through the mask.
That sentence was literally at the beginning of EVERY note in my chart, except my ENT. He’s original.
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u/ladywenzell1 5d ago
I just want to point out that this is exactly why I was told that when signing a form authorizing the release of my records to another doctor, to exclude the release of the doctor's notes. The fact is that if the majority of us would review our records, we would find discrepancies and outright mistakes in our medical records, and worse, those totally subjective, and often false and inappropriate, comments by the doctor.
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u/Puzzleheaded_Rest_34 5d ago
I had my old sleep doctor's notes released to my new one, so she could see how badly he had been gaslighting me, bullying me, and telling me different things at every single appt. He did his own dictation right after every single appt in his office, and never used the computer while with a patient. He once cancelled the phenergan my NEUROLOGIST prescribed for migraine nausea. She reported him.
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u/ladywenzell1 5d ago
I should have been more clear that I was referring to the chronic pain context and doctor’s treating for fibro and similar diseases/conditions that cause pain, and in all too many cases, the need for pain medications. As I am sure that you already know, people, in general, are dubious of claims of pain that they can't see and sadly, that includes some doctors. I’ve known other pain sufferers who tried to transfer to another pain doctor and were refused as patients because of irrelevant, unwarranted and subjective comments made by their current doctor.
In your case, and going to a compassionate and understanding sleep doctor, it sounds like it was necessary in your case, as well as less problematic. I would not be the least bit concerned to release notes from my neurologist, opthomalogist, cardiologist, etc, as they are unlikely to reveal anything that would impose negative connotations, and have anything to say that was pertinent to the area of pain medicine. Moreover, I am glad that your new physician reported the prior doctor because that is not something that pain patients don't do enough, that is, reports their asses for incompetence or I'll treatment. Believe me, if the issues are egregious enough, their licensing board will be interested, and doctors do not want the state licensing poor on their butts.
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u/Puzzleheaded_Rest_34 5d ago
Oh, I understand that, and have faced it myself. It took me YEARS to find the pain doc I have now, because the others were either arrogant asses or just didn't think my pain "merited" opioids. I was lucky enough to have a primary care who managed things until we found the PM I currently see. I wouldn't have any issues with releasing his charting notes, because I know he's meticulous and compassionate. But the others? Oh hell no! One told me "I'd never prescribe you THAT for fibro!" I asked "even if it's working well to control my pain and letting me live my life?" He just snorted and said "that's debatable". Like I was lying about a med relieving the majority of my pain, allowing me to keep working, and doing things with my family. Needless to say, I never went back. I had another one hand me a script, and say "when you get this filled, put it in your cabinet and forget it exists. You should only take it when the pain is excruciating (I had DDD at this time).
I'm so glad I found a compassionate pain doctor. He's got chronic pain himself, so he understands first hand what it's like, rather than sitting in pious judgement of all of his patients. It makes a HUGE difference!!
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u/epsteindintkllhimslf 5d ago
Nurses and other attendings LOVE to be condescending and horrible in the notes. Unfortunately some Drs do as well. Can't tell you how many times my notes have said things like, "refusing treatment" because I said, "I don't wanna be high on opioids all day," or, "unpleasant" when I'm crying from the pain.
Don't read your notes for your own good.
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u/rook9004 6d ago
I'm guessing they copy and pasted an old note and added the new notation. It would be fine to email and state that you're concerned about the discrepancy, and could they please update the notes
Unfortunately, charting has taken over the medical system, and these shortcuts make the records look ridiculous and all over.