hart

SW:

Under HIPAA, patients have a right to amend their medical records. Here is a link to the US Department of Health and Human Services information pertaining to your rights in regard to your medical record. (I am assuming that the encounter took place in the US.)

Note: this forum does not allow urls so I have inserted 3 spaces in the address. When you cut and past this into your browser, you will have to delete these spaces before pressing return. (Let me know if you are unable to access this info!)

ht tp://ww w.hhs.gov/ocr/privacy/hipaa/understanding/consumers/medicalrecords.ht ml

“Correcting information
If you think the information in your medical or billing record is incorrect, you can request that the health care provider or health plan amend the record. The health care provider or health plan must respond to your request. If it created the information, it must amend the information if it is inaccurate or incomplete. If the provider or plan does not agree to your request, you have the right to submit a statement of disagreement that the provider or plan must add to your record.”

Cheers,
H

I had a VERY similar experience although the spine surgeon in question is well established and possessed reasonably nice “bedside manner”. He performed NO physical exam. He stood in front of the computer screen and I sat in a chair, fully clothed, probably 8 feet away. He commented on an MRI of my T-spine. (Perhaps, I shouldn’t have let him see it!) I was complaining of neck pain.

I did not have any recent cervical spine imaging. The nurse required me to have office X-rays of the neck BEFORE I saw the doctor for the first time. (Axial views were not obtained, incidentally.)

I asked for a “report” on the C-spine film (for my records) which I think the surgeon is required to record if he is billing for both the technical and professional component of office x-rays. (Incidentally I was charged $15 for a CD of my X-ray.) I was provided with the “notes” from my visit. Reflexes, strength, ROM were graded. Babiniski and Lhermitte were negative, etc. All signs were reported to be negative or normal. He did note one positive “finding”…slight pain on rotation. In the history, he did get as far as “chief complaint”. I had told him that it hurts to turn my head and that I couldn’t turn it very far.

Over two decades ago, I sustained a C7 anterior vertebral body fracture landing short…very short…on a back flip. Over the years, I have been told this is a “typical” injury. During the visit I told the surgeon about this and he quickly pointed to the X-ray and said…there it is. In the notes he recorded this as “C7 spinous process fracture’. My FP and I were curious about this so she sent me to an “imaging center”. I wrote the radiologist a letter explaining the injury, my FP’s concern (about chiropractors!) and asking for a comment on C7. We got the comment. In all fairness, the changes are subtle…my chiropractor told me that it is the stuff that chiropractors always see but radiologists may miss if not pushed. Maybe it is OK if the surgeon missed a somewhat subtle change in shape of a vertebral body after so many years of bone reformation. However, he reported an old spinous process fracture…which never existed.

But THIS is what really got to me! I had previously seen a PM&R who works in the same office for evaluation of a large thoracic disc herniation and corresponding radiculopathy. (I do have a thread going on this and I am ever grateful for your help!) I chose a PM&R at that time because a couple spine surgeons who had seen my MRI (though not me) said injection was my best bet. The PM&R had highly discouraged me from injection. He told me that this would be pushing me one step closer to surgery…silly logic. (Interestingly, the PM&R also told me that “these problems are very easy to fix…small operation”.) Anyway, the spine surgeon recorded in his notes that I had refused injection to the thoracic spine during an appointment with his PM&R colleague six months earlier. The reason I saw the PM&R was to get a referral for injection!

I did see the surgeon once more to review the results of a C-spine MRI that probably wasn’t indicated in the first place. (This group owns an MRI.) I did “confront” him about the injection comment and set the record straight. He told me that I need to understand that transcription errors occur. He did not offer to amend his comments. I did not mention his comments about C7 fracture. I don’t think this is my place. I did though send him the detailed report I obtained from a radiologist about the changes at C7 which the radiologist stated were consistent with vertebral body fracture and the mechanism of injury. As for the fabricated physical exam, I did not say anything. However, I think he practices in a field where there is some likelihood of limitation after surgery… some real “exposure”. I think it would have been in HIS best interest to perform a thorough physical exam and carefully document any “preexisting” limitations.