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dai1015

Doctor writes both facts and fiction in my medical notes

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I had a bad experience with a doctor and in my medical records the notes from that day state some facts but also some untrue events. I believe these untrue events make me seem like an extra difficult or irrational patient and any future doctor may deny me care because of it. Do I contact the doctor to correct? should I call or write a letter? it is legal for her to do, and how can it be proved? Thank you.

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When you say, untrue events, are you saying that she is saying things happened that didn't happen at all, or that her version of what happened does not match yours?

 

Let me give an example of what I mean. You come into her office, you're thinking about something and by accident walk into a chair. The chair falls over. Your version is that you walked into a chair and it fell over. Are you saying that her notes say,

 

a.) Jane knocked over a chair or

b.) Jane picked up the chair and threw it across the room?

 

 

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my example: Doctor states that I denied pelvic exam several time in report. In reality the doctor never suggested a pelvic exam, only the RN did before the exam actually started and it was regarding another issue not the reason I was there or that the Dr. was referring to. Another example: Doctor states after I "became unable to calm down" she included a chaperone for the remainder of the exam, but in reality the exam was over and I was on my way out of the office when I approached her and asked about her behavior only then we went back into the room with another staff member.

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So, the medical record says you denied a pelvic exam and the doctor included a chaperone because you did not calm down.  Why would you expect those statements would make another doctor refuse to treat you?   Incidentally, why were you agitated?

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It all implies that I was being more difficult than I actually was. She goes on to make it seem like I'm making things up and changing my story through out. while I was upset and that's a fact I know some of the facts are incorrect to her advantage. She even spelt my name wrong too. I requested not to see this Dr anymore and was told to leave the practice.. no one every asked what happened and why I was so upset. They just have her record of the event. I just want my medical record to state that facts and not her spin on it. I was upset and crying after the exam but that is not mentioned. I was denied care from another practice after they reviewed this record already. I cannot prove any of this or how she spoke down to me when I was on my back belly exposed. Im pregnant and need care for my OB needs and because of the way she makes me sound like a crazy person I am  being denied care. I don't know how to handle this? ask her to correct?

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If you feel your medical records are not accurate, you have a right to request that the doctor correct them.

 

45 CFR 164.526.

https://www.law.cornell.edu/cfr/text/45/164.526

 

The regulations include:

--a procedure for requesting a change,

--the time periods for a health care provider to respond to a request,

--what health care providers are supposed to do if they agree with the request,

--the bases upon which a health care provider can deny a request for a change, and

--the procedural requirements for a denial.

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