“She became dizzy and came to the emergency room for further evaluation”

Remember my post before last, Melena, Hematemesis, Hypovolemic Shock — and A Lot of Love? You know, the one about vomiting up great tarry mounds of clotted blood, losing consciousness, and getting oxygen and IVs in the ambulance before it left my driveway?

Well, today I went to hospital to get my medical records from my latest stay.  And here is what my History & Physical report said:

Sunday night the patient found the blood in her stool. The patient had hematemesis this a.m. Patient came to the emergency room.

Now the Consultation Report. It has the same time inaccuracy: my melena [and if I can use the correct terminology, why can’t they?] didn’t occur Sunday night but just a few hours at most prior to my hematemesis. The report goes on to say:

She became dizzy and came to the emergency room for further evaluation.

And now the Discharge Summary, same misinformation regarding melena, then:

On the day of admission, she vomited coffee-ground materials, got dizzy, and came to the emergency room.

Three reports prepared by three different doctors, each wrong about the timeline, and not a whisper in any of the three about what happened before I arrived in the ER.

There are other annoying things, like under General Impressions in the History & Physical, there’s this observation:

 a  trace of blood around the mouth

but not a word about the globs of dried blood in my hair. Never mind.

The biggie, obviously, is where are the narrative and the record of my vitals for the 20 minutes prior to my arrival? Even if it is not the hospital’s responsibility to incorporate these into the record of my stay under their roof, shouldn’t there be some mention of my means of arrival? Isn’t it downright deceptive to write:

She became dizzy and came to the emergency room for further evaluation …

… got dizzy, and came to the emergency room.

These statements are not untrue: I was dizzy before I started vomiting blood and lost consciousness. And I did come to the ER for evaluation. Not untrue, but  nonetheless false.

When I told the Records Clerk something was wrong, she called in a person who I will call the Conciliator. She’s the one who says, oh I’m so sorry this happened dear, but I haven’t a clue why it did, who is responsible, or what can be done. By the way, why did you come to get copies of your records, anyway?

Because they are mine, I replied. Silence. Because they are mine and no one cares about my health more than I do. And I like to know what is going on.

We left it with the Concilitator promising to get back with me in a few days, when she learned something about anything.

We’ll see.

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5 thoughts on ““She became dizzy and came to the emergency room for further evaluation”

  1. The actions taken by the ER were correct: they fixed the problem, so I don’t think at that time fear of litigation had anything to do with anything. It’s not what they did, but how they recorded the history of my problem that is incompetent, downright bizarre. They had to have an EMT report, I’m sure, although I didn’t get a copy when I requested my records. And certainly what is in the EMT report has to have at least as much relevance to my recent medical history as my trip to AZ does. If that EMT record is missing from my hospital records, and I’m paying another visit today to deliver my complaints and demanding to see it so we’ll soon find out, then yes indeed they can start developing a fear of litigation. Is it any wonder that hospitals make it so difficult to get a copy of your own records, i.e. coming in person, paying $1.00 a page?

  2. Unbelievable! Are these doctor’s actually paying attention? Could not help but wonder if they toned your record down in fear of litigation of some sort? I have a hard time getting my head around this as the evidence was so overwhelming!

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