I wish I had the ability to understand why medical professionals would think it’s okay to lie in a patients chart. I used to believe that medical professionals were honest. That they did the best that they could, in a compassionate manner. That they were held to a higher standard of responsibility to be honest especially in a patients chart. As time went on I learned that wasn’t the case. This most recent example of that is when a nurse entered into my chart that the doctor and I had a lengthy discussion about several issues. When we didn’t have a discussion about anything on the date in question.
In fact, I haven’t seen the doctor in question in years, nor have I been to their medical clinic in over a year. The first, and last, time I saw him he lectured, body shamed, and shamed me about my health. Then he leaned over, pointed his finger at me, and said, “Someone with your lifestyle needs to be tested for all STD’s on a regular basis.”
It was news to me. I’m a heterosexual woman who hasn’t had a boyfriend in years. What he did at that moment was horrifically wrong. The body shaming was wrong. Casting judgement on a patient because of their “lifestyle” and only then to be concerned about STD testing; is wrong. I can only think that someone at the clinic put into my chart that I didn’t have a boyfriend so that meant that I must have a girlfriend. Which where flattering, isn’t true and a bad assumption for anyone to make. Since then I’ve not been asked by anyone there if I have a boyfriend. The appointment just over a year ago with another doctor, he knew I had the appointment coming up. That doctor spent at least twenty minutes body shaming me and telling me that every health issue I have is because of my weight. Even though I mentioned something about my heart to her, she didn’t even listen to my heart that day. Nor did she perform a breast exam and just ordered the mammogram. Instead she told me that if I would just care about my health, exercise, and lose weight then I’d have no health issues. Which was like a repeat of the body shaming that he’d done. Even some of the nurses there have body shamed me.
So, the nurse in question was going through the doctors patient charts and updating the “visits” and “after summaries” to include all telephone calls. The software in question has a location for recording phone calls. But apparently they have to put them in the Visit list, even though that’s incorrect. She went back years and put in that calls that were merely voice messages left on my phone were “discussions” with the person listed on the entry. On the date in question she entered: “Doctor Bully’s Name; March 7: You had a discussion today with Dr. Bully about the following issues.” In the notes section it shows that on March 7th she notified him that I needed a wide range of blood tests done and other screenings done; and could he please order those? For a patient he hasn’t seen in years and hasn’t been seen in the clinic in over a year. His response: “Thanks. Ordered!” She then on March 9th left me a voice mail message and through the patient portal sent a letter to let me know what I was missing in tests. She also informed the schedulers that they were to schedule me for those test when I called in for my next appointment. She left another message on the 16th.
No discussion with the patient necessary. No visit. No communication past: I, the nurse, have decided you need tests done and the doctor agrees. You will comply and get the tests done as soon as possible.
I can go there because in a past communication with the doctor in question he said, “I won’t force you for now to take the medication.” Which was nice of him considering that the medication in question has no effect on me, other than a slight allergic reaction. When I told him that he shook his head. Did the medication get put onto my chart as such? No. Then he went on a body shaming rant; and sent in a prescription for that medication.
My brain upon seeing this fictitious entry into my chart hiccuped. I was stunned and shocked. I was also upset. I wrote a note and asked what was up with the entry and would I get charged, cause that’s a concern. Mostly I wanted to know why there was a fictitious statement in my chart. His reaction was to tell the nurse to call me to discuss the phone call with him on March 7th, and the documentation procedures of the clinic. She left a phone message to state that. Then in the chart she elaborated and mentioned medical conditions they were testing for. I cringed at the difference between what she actually said in the voice mail message, and what she wrote about the phone call. The two were similar but held discrepancies that given the minutes between the two shouldn’t have been there.
I wrote back and clarified that no such discussion or call happened on the 7th. That it was the 9th that she left a voice mail message and that’s in the chart. She told me she had to do the documentation in the method she did. That because of the medical conditions they needed to test for she had no choice. It was the only way that the doctor could order the tests. It was no big deal and okay for her to write that fictional statement into my record. In almost every paragraph she repeated the medical conditions that the tests were for. She also said that they are concerned and care about me as a patient and want nothing but the best for my health.
She didn’t have to say it, but the implication in all of what she wrote was that I’m the one that obviously has the issue. Because I wont just do what they are telling me to do. I won’t jump when they say jump. I won’t take medications that I know I have an issue with, and/or do nothing for me. Because I question what they put into my chart when it’s incorrect. I speak up and tell them my opinion and thoughts. I look into things and want explanations. I can’t tolerate lies from medical professionals. Even small ones that seem harmless, because there’s no such thing as a harmless lie in a persons medical chart.
I care about my health. Which is more than I can say about them.
I’m in the process of shopping for a new clinic and doctor.
What Can You Do?
Most clinics, or hospitals, have contacts for logging complaints against medical employees and other employees. In the past I’ve learned that they will look into the issue, and the letter that one gets back will be mostly a “covering our asses” letter. It might lead to changes that happen at the clinic, but most likely the patient won’t know about any disciplinary things that happen to the people in question.
If it’s a big enough issue there is always the Medical Board and Health Care Authority in the state where you live that you can contact. In this case, I had a question about if it was legal for the nurse to have done what she did so long as there were no charges. To date my note has been forwarded to two different area’s inside the Health Care Authority of my state. Two employees there don’t seem to be able to answer that one simple question for me. However, they did let me know who to write to with a complaint about a nurse.
A Leisurely Chat 