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Getting a doctor to amend a report

Old 12-01-2016, 02:21 AM
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Default Getting a doctor to amend a report

This is bugging the crap out of me.

Doc wrote up a report.

He was a referral from another doc (specialist) well somehow the specialist came up with an opinion that is not factual not based on my history. My medical history is incorrect, he didn't even ask me any of the questions that would lead someone to even consider this, and the only way to make this diagnosis is to either have solid historical evidence like a family member saying something, actually observing it happening, or some other way of obtaining first hand knowledge or the patient telling the doctor about it.

None of that happened. The diagnosis is inaccurate. Other stuff in my medical history with this doc is wrong too, like saying both or my parents had strokes which neither has.

Further, it is not in his list of diagnoses, just on the referral. Doc who wrote the report is refusing to listen or amend, doc who sent it is brushing it off despite me talking to him about it repeatedly.

Doc who wrote the report said if I don't like it call his lawyer. So I called mine. He said basically the doc can write whatever he wants and doesn't even have to support it with any evidence.

WTF? Don't they have an onus to make sure it is factual and not a misdiagnosis? Apparently not legally.

Any ideas how to resolve it? I'm feeling like employing the Capt Nate solution but that's probably not going to get me anywhere. I don't care about the doc who wrote the report but don't want to alienate the specialist I see regularly.
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Old 12-01-2016, 02:34 AM
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You can file a complaint with the Board of Medicine in the state the physician practices. Contact the Board. They will give you instructions how to file and report said complaint.

Your complaint will be investigated. That is the job of the Board of Medicine. They will contact the physician and expect an explanation from the physician.

You can also contact any hospitals the physician has privileges. If there is no hospital involved you can expect no action. (You do not say if the consult was an office visit vs a hospital visit) Hospital staffs are interested in physician errors happening at their institution.

It is unlikely the report will be changed. The advice you received is probably correct. The physician can opine anything. Physicians are allowed to make judgements and errors. This happens all the time.

I'm no lawyer, but you do have to have injury to expect any legal recourse.

Be very civil and specific in any correspondence. No emotions. Just like Dragnet---"Just the fact's ma'am" You may also ask your primary physician to enter your comments regarding discrepencies into his/her medical records.

Good luck.
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Old 12-01-2016, 04:24 AM
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Originally Posted by dssmith View Post

I'm no lawyer, but you do have to have injury to expect any legal recourse.

Good luck.
Correct. Unless the OP can demonstrate how he has suffered from either financial loss, or pain & suffering, there isn't much basis for a lawsuit.
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Old 12-01-2016, 04:34 AM
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Originally Posted by dssmith View Post
You can file a complaint with the Board of Medicine in the state the physician practices. Contact the Board. They will give you instructions how to file and report said complaint.

Your complaint will be investigated. That is the job of the Board of Medicine. They will contact the physician and expect an explanation from the physician.
That's it.

I had a "polyp" removed during my most recent colonoscopy. I knew this guy would "find something." He just smelled of overzealous, ding-the-insurance-company-itis. Pathology showed it was not a polyp. I sent him a letter asking him to amend his surgical report and change his follow-up recommendation from three years (normal for people with polyps) to five years (normal for people with no polyps).

No response at all. Jerk!
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Old 12-01-2016, 04:49 AM
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I have a couple tales but can only share one.
Went to the ophthalmologist and the nurse went through the usual 90 questions. When she was done, did the usual "the doctor will be here in a few minutes" routine. She left my file open on the computer where I read "patient says blurred vision is impairing his ability to drive". WHAT????? Doctor comes in and I say "There's no way that I made that statement!" I told the dr that what I said was that I used to be able to see a stoplight from a mile back and now I'm down to 1/2 mile. I can still see good enough to drive.
He looks at the nurse and she says it's the way the computer auto-populates that field during the questioning.
Doctor says "I can understand that being a giant liability issue. I agree and tell him that's why I object.
He makes the nurse change it while we wait.
Short of it is ALWAYS read your file. If it's not right, get them to amend it or to add your objection. If they refuse, at a minimum respond with a registered letter and keep your letter on file.
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Old 12-01-2016, 06:41 AM
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Originally Posted by nicecast View Post
That's it.

I had a "polyp" removed during my most recent colonoscopy. I knew this guy would "find something." He just smelled of overzealous, ding-the-insurance-company-itis. Pathology showed it was not a polyp. I sent him a letter asking him to amend his surgical report and change his follow-up recommendation from three years (normal for people with polyps) to five years (normal for people with no polyps).

No response at all. Jerk!
In my experience, 5 years is normal follow-up frequency for people with polyps and 10 for those with none.
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Old 12-01-2016, 07:18 AM
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You can get another opinion and have that doctor address the issues that you are concerned about, then you will have it cleared up in your medical record.

Also, you can write the doctor a certified letter, addressing the issues that you have, request that his staff add it to your medical file. Then it becomes part of your medical chart.

Unless, there is some sort of disability or lawsuit pending on the information there then there is very little reason to press the issue with the current physician. Just let it go and clarify it elsewhere with another opinion or with legally addressing the issues yourself.
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Old 12-01-2016, 07:30 AM
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Originally Posted by SeaJay View Post
Correct. Unless the OP can demonstrate how he has suffered from either financial loss, or pain & suffering, there isn't much basis for a lawsuit.
A false report could make it hard to get life insurance etc. so there you go
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Old 12-01-2016, 07:32 AM
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Consider sending a certified letter to the doctor's office, requesting a copy of their HIPAA disclosure and a written statement regarding their policy to address errors in the medical record. [There should be a policy, and a written statement.] Usually, the prospect of being investigated for a HIPAA violation is enough to make offices respond.

Standard practice is for there to be a process wherein a patient can request that an amendment *written by the patient* be attached to the medical record, so that any further disclosure of the erroneous record is accompanied by the amendment. This may not get the erroneous information removed, but should mitigate any potential harm from the information.
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Old 12-01-2016, 07:38 AM
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Can you go into your drs office and request to see your entire file to see what's actually in it? Never thought about this before reading this thread.
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Old 12-01-2016, 07:55 AM
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Originally Posted by amofgreenville View Post
Can you go into your drs office and request to see your entire file to see what's actually in it? Never thought about this before reading this thread.
Yes you just fill out a release form. Some times there is a 3rd party that manages their records so it takes longer to get copies.
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Old 12-01-2016, 08:00 AM
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Originally Posted by jhuffman228 View Post
A false report could make it hard to get life insurance etc. so there you go
Yes and that is somehow unquantifiable and there is no losses until it actually happens. I'm wondering if the attorney fee to send a letter to try and resolve it, plus the cost of court filing fees would be a "loss" enough for small claims and then hope to convince the judge to compel to correct the info if it comes to that.

It's so stupid they want to waste $ on attorneys all over arrogance.

Dr Dan thanks for that info. I will look at pursuing that route. I really don't want to alienate the specialist so I'm trying to find a route that keeps an amicable relationship. The other guy is in his own practice just him and a receptionist I'm never going back to him for various reasons but it's his report that needs the item in question removed.
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Old 12-01-2016, 08:21 AM
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have you thought about getting a report from a different Dr showing that the other report is not factual.
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Old 12-01-2016, 08:30 AM
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Might as well lawyer up. Its the only thing that is going to get their attention.
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Old 12-01-2016, 08:32 AM
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I would highly recommend a better doctor.
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Old 12-01-2016, 09:01 AM
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I had a cardiologist put me on high blood pressure meds. All of a sudden my blood sugar goes up and they put me on Metforman. Made me mean as a snake. Told the doctor something is wrong. I have never had any sign of diabetes. Then he says your cholesterol is high. I want to put you on meds. I said no, my cholesterol has always been 157. Something is wrong. I researched Azor, guess what? Side effects -high blood sugar, high cholesterol. Stopped the AQzor and in two months A-1C 6.1.
She keeps talking about controlling diabetes. I argue I am not diabetic, the high blood sugar was drug induced. She still won't amend my record to say I am not diabetic. Labeled for life.
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Old 12-01-2016, 09:12 AM
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From HIPAA website:

Corrections

If you think the information in your medical or billing record is incorrect, you can request a change, or amendment, to your record. The health care provider or health plan must respond to your request. If it created the information, it must amend inaccurate or incomplete information.

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.


http://www.hhs.gov/hipaa/for-individ...rds/index.html
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Old 12-01-2016, 10:03 AM
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Originally Posted by DrDanH View Post
From HIPAA website:

Corrections

If you think the information in your medical or billing record is incorrect, you can request a change, or amendment, to your record. The health care provider or health plan must respond to your request. If it created the information, it must amend inaccurate or incomplete information.

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.


http://www.hhs.gov/hipaa/for-individ...rds/index.html
Crazybeard,

DrDan provides the best and most reasonable route for you to go. Do as others have recommended and send a certified letter with the correct information regarding your medical history to the physician you disagree with. Send cc. letters to any and all other relevant providers for their files. Keep a copy for your files.

The medical record is any information regarding you. The medical record can be video, audio, written, computer generated, letters, etc etc etc. The physician's file is only one part your your medical record.

Don't give what you are doing a second thought. Updating and correcting medical information is your right and responsibility. If a physician or anyone else is insensitive to your concern they are in the wrong. Conflicting information showing up in medical care is rather common. More common than you might think. Working with providers you trust is most important.

AmofGreenville: Your information is yours. See link for quick answers to all medical records questions raised in this thread. http://www.hhs.gov/hipaa/for-individ...dical-records/
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Old 12-01-2016, 10:24 AM
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Originally Posted by dssmith View Post
Crazybeard,

DrDan provides the best and most reasonable route for you to go. Do as others have recommended and send a certified letter with the correct information regarding your medical history to the physician you disagree with. Send cc. letters to any and all other relevant providers for their files. Keep a copy for your files.

The medical record is any information regarding you. The medical record can be video, audio, written, computer generated, letters, etc etc etc. The physician's file is only one part your your medical record.

Don't give what you are doing a second thought. Updating and correcting medical information is your right and responsibility. If a physician or anyone else is insensitive to your concern they are in the wrong. Conflicting information showing up in medical care is rather common. More common than you might think. Working with providers you trust is most important.

AmofGreenville: Your information is yours. See link for quick answers to all medical records questions raised in this thread. http://www.hhs.gov/hipaa/for-individ...dical-records/
Can you pull the medical records all together so no one other than you has a copy of it, not even the drs. office?
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Old 12-01-2016, 10:42 AM
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Thanks dssmith. I'm going the Hipaa route right now. Also filing a state complaint and the lawyer will be sending a letter. Even after the "talk to my lawyer" I had emailed and said it would be in our best interests to not go this route but of course that is being stonewalled so I figure do them all at once.
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