The Case of the False Medical Records

Yes, false records.  In the midst of the million emotions that are flooding my mind right now, the issue of the false medical records keeps surfacing.  Clearly, it is the last thing we want to be worrying about right now.  You would think that we had enough to mull over, right?

After all the wonderful comments and personal stories that others shared with us (thank you, thank you, thank you!!!), we are convinced that I did not receive the best care.  This fact is magnified by the inaccuracies of the report made by my fertility nurse the day I went in doubled over in pain.  While some of the errors are very minor, many are not and do not paint an accurate picture of what occurred during the appointment.  Likewise, there is an error in the hospital records.  So, here's my list . . .


"Pelvic Pain began gradually 6 days ago and has remained at about the same level of intensity."
 Correction:  The pain had started 6 days ago, but had gradually increased so that every step hurt, every bump, every bodily function--all things that we discussed in length.  


"There are no aggravating factors."
Correction:  Perhaps this means something else I am unaware of in the medical world, but aren't all the things I just listed aggravating factors?  How about our discussion about pain during eating or intense pain in my abdomen during urination?  


"Given Percocet for pain"
Correction:  Vicodin


"Rates abd pain at 6 of 10."
Correction:  At that moment, yes.  Discussed how there are instances where the pain is at a 9 or 10.  Even wincing while drinking a dixie cup of water in front of her because of the pain.


"Normal gait."
Correction:  hmmmm....how do I not freak out about this one?  Normal gait?  Really?  I couldn't stand up straight, was walking at a ridiculously slow pace.  I even asked on my way out, so the pain meds might help me get around better?  stand up straight?  Her response:  Well, that will just take time. 


"Offered ultrasound"
Correction:  Yes, I was absolutely offered an ultrasound, but in this way. . . "We can do an ultrasound, but we already know what we'll see.  You're hyperstimulated."  We went on to ask her recommendation about three times, to which she repeatedly said she would not recommend an ultrasound.  


Instructions:  Schedule Ultrasound
Correction:  No such instructions were given.


Upon admittance to the ICU:  "Patient received fertility labs on Monday visit."
Correction:  My hemoglobin was checked.  Clearly not all that needed to be tested.  


It's a long one!  Most of these are from one report, one clearly false medical record made by the very Auntie Dumplings that I have trusted in for so long.  It is sad.  I don't mean to say that she purposely falsified the records in any way, but the paperwork is not accurate.

After hearing my OHSS story and looking over these records, so many people have told me I have a lawsuit on my hands, to go to the attorney general, to go after her.  I will not.  I could never do that to another person.  I dealt with her in my own way, albeit a very gentle way.  In fact, after I was discharged from the hospital, I called her and left a voicemail, rattling off all the scary test results and OHSS symptoms I had had over the last week.  After I hung up, my mom said, "I thought you were going to be harsh."  What's the point, I thought.  Yes, I wanted her to know everything that had happened.  I wanted her to feel a little guilty even.  I wanted her to make sure she gave better care in the future.  But it does not do me any good to be a bitch.  She called back and predictably apologized that this happened, saying (much like everyone else) that she had never seen such a severe case before.  It was nice to close out with her.  I told her I was canceling my appointments with her as I had to go to the other office for follow-ups already.  I told her that we needed time to figure out where we would go from here.  She understood and kindly told me to call her if I needed anything.  It was the most civil break-up I've ever been through and I wouldn't have it any other way.

Still, I do want my records accurate for the sake of myself when my records are transfered to another clinic and for the sake of the clinic itself, so that they are diligent about their record keeping.  The last thing I want is for this to happen to another person, but how will the extent of the problem be known or understood if the paper trail is littered with inaccuracies?

I am confused about where to go with this complaint.  Do I talk to the doctor I have now been seeing?  The office?  Most of the staff had no problem calling my Auntie Dumplings out and blaming this entire fiasco on her, but that is not an official action.  And I officially want this changed.

So, I turn to you again.  You were all amazing with the feedback on my OHSS.  Every little bit helped us understand a little more what happened here and what should have happened.  We are so thankful for the openness of complete strangers!  I want to move onto my life.  I want to address all the serious emotions I am having, to feel my way through this difficult time, to find where our path will lead next.  I do not want to be worrying about medical records.

So, any advice?