Chronic Pain Patient Records – Are They Accurate?

Chronic Pain Patient Records – Are They Accurate?

radnovich

Dr. Richard Radnovich, D.O.

Editor’s Note: Dr. Richard Radnovich is a National Pain Report contributor who has been writing on the patient-doctor relationship. Today, he addresses the issue of patients records.

I received an email from a reader who had a question and concern about what is in her medical records that may be keeping her from getting the care she deserves.

Patient: Medical records and “telephone conferences with past providers” are not always accurate. There HAS to be some recourse, NO? I asked my PCP WHAT is in my file and she coyly said she didn’t know. NO-ONE is addressing the problem of inaccuracies, bias, subjective opinions, and the denial of needed pain medicine.  I have to have a way to see and correct whatever is in my file that is preventing me from receiving pain medicine.

Dr. Radnovich: You have every right to see what is in your file. The information in your file is YOURS (well the content is, not the paper itself). No provider can keep you from seeing it.

Reviewing medical records is not a necessity, but if you are having issues, it is reasonable to see what they say. Go to all the places that have given you care and get a copy of your medical records.

For physicians in private practice, simply ask the receptionist for a copy of your office notes. Do not make a big deal of it, the doctor does not even need to be involved. If you have been a patient for years with a particular office, you do not need chart notes going back forever. Maybe just the last year, or from around the time the relationship with the doc went bad. Just tell them you want a copy for your records.

For hospitals, call the medical records department (sometimes called Health Information). If you have been an inpatient (stayed in the hospital overnight), most of the time you really do not want ALL the records. What you need is the “discharge summary” and the “admission history and physical” for each time you stayed. If you have only been in the ER, get just the ER notes for each visit.

You should also be able to see your board of pharmacy report. You might need to call your state board of pharmacy to get a copy of your profile. This profile is available in most states and shows all the controlled substances that were dispensed to you. You should also contact your pharmacy itself and get a print out of all the medications dispensed in your name.

Once you have these records, go through them line by line. Look for significant problems. If you had your gallbladder out in 2001 and somewhere it is noted as 2003, that is not significant. But if the pharmacy monitoring program documents that you were given #300 Norco but you never get more than #120, that is significant.  You want to pick your battles. Choose to correct the things that make a difference.

If any of these providers try to keep information or records from you, remind them of their responsibilities under the Health Information Privacy Protection Act (HIPAA). If you find significant errors, your medical provider, pharmacy or hospital cannot simply remove bad information. But they are required to correct the data if possible or enter your corrections or comments.  More information about your rights can be found here: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/medicalrecords.html

Have you tried to get a copy of your records and review them? How did you handle it? What worked and what did not? Let us know, maybe you’ll be helping the next Chronic Pain Patient.

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Dr. Radnovich is a nationally known chronic pain physician and researcher. Here’s more information about him and his practice.

Questions for Dr. Radnovich? Email him at editor@nationalpainreport.com

There are 6 comments for this article
  1. Kathy Cooper at 10:25 am

    My Medical records are disturbing and contradictory. I was advised to just leave it alone, it is too stressful to deal with. That was 15 years ago. I have had Doctros names redacted from surgical Reports, information left out. One Doctor claimed that “PT Should not be encouraged by reviewing her imaging”. I have a Pain Specialist that disregards most of this, yet my former PCP of 8 Years wrote some non factual and misleading things in my File. He wrote that he “counseled me during every visit to reduce my Medication usage”. This never happened, and I have several spine conditions that are unlikely to get better. I have had 2 spinal surgeries, one with a C-spine implant, I have Degenerative Disc Disease, Spondylosis, I have MRIs that show all of this, yet I know I have been denied care because of some of the comments. I have had to have imaging re-done because of the long interval it takes for referrals. I have had to have Nerve Conduction Tests done on the wrong part of my body, because the referrals were incorrect, etc. I have tried to get a review of my case, by Medicare, thinking it would save them money.
    I was alleged to have some sort of Mental Illness when I first tried to get a diagnosis for my back pain. I had injured my Lumbar Spine, and I was trying to go on with my life. I used Chiropractic, NSIDS, Massage to try to alleviate the pain, but it got worse. As it got worse I could no longer work, and my life became really unmanageable. I stupidly though that if a saw a Psychiatrist, they might figure it out. Instead I was labeled. I remember driving to the appointments in pain, and unable to sit, because the damage to my L-spine and tailbone made it impossible. I tried to get a referral for imaging, but was repeatedly denied. Six years later, I had an MRI, that showed the ruptured disc, and damage to the nerve root. I cannot describe the pain, which I tried to force out of my mind. I was making myself worse by “Exercising” and trying to keep working and attending College. It never even occurred to me to take Pain meds other than NSAIDS. I was given every kind of Psych medication, I though if I went along with it, they might figure it out. There was a constant implication I was just not “Trying hard enough”. I had my first L-spine surgery 2 weeks after the MRI. I had nerve damage from the disc compressing the nerve root. I was still in pain, and I tried to function, it only made it worse. After the surgery I was told “I just did not want to get Better”.
    15 Years later this kind of thing is still going on. I am afraid of what might be in my medical records. Some of the incorrect information has led to me being ignored when I tried to get a diagnosis or treatment. I don’t know how to disprove or prove the false information. It would seem it was contradictory. I have ben waiting for a surgical referral now for over a year, and getting worse. This has been a pattern. I used to think that I might get my life back after a surgery. I now know that all that will happen is a percentage of pain might lessen. I might be stupid, but I feel that my initial misdiagnosis and the postponement of treatment, or a real diagnosis, have led to permanent chronic pain.
    How do I correct my Medical Records, no amount of contradictory evidence seems to fix anything? I have tried. My C-spine implant is failing, I have tried to get a Medical Opinion, or advice for 3 years now. My Specialist showed me the latest MRI and it looks pretty bad. I tried Nerve ablation, already but it didn’t help much. I had a referral 2 years ago, but they did a nerve conduction test on my leg. This was for the neck pain, I really don’t understand. I tried to speak up for myself, but that only makes this worse! The referring Doctor did not put the correct information on the Referral.

    Kathy.

  2. Christine at 10:00 am

    My doctor gives mea copy of his referrals. In hospital I have read my records, they were handed to me to take to Radiology so while I waited, I read them. When they have been left at bedside, I read them. I have a good relationship with my health professionals.
    As for the 1-10 pain score I find it hard to translate pain to number. I was told that 10 would be the pain if arm was sawn through with a chain saw and 1is mild discomfort. It still does not help me any. It is like trying to describe child birth it is different for everyone. Renal colic is worse than childbirth was for me. Fibromyalgia is like a migraine all over my body. Or like the worst influenza aches and pain only worse. My arms and legs feel weighted down, everything is such an effort. I am glad I live alone. My weird ways of functioning is not bothering anyone else. I have wonderful help. Even the mailman brings mail to my door so I don’t have to walk to letterbox. That is so nice, he has seen me struggle during flare ups. The pharmacy deliver my medications.

  3. Concerned at 4:23 pm

    Sadly, some states like Alabama explicitly forbid patients from seeing their PDMP REPORT. I’ve had numerous mistakes on mine that fortunately haven’t impacted my care – only because I wonderful physician who knows me and knows to ask questions.

  4. Frances Gilbert at 4:17 am

    My physician (PCP) and I work together as a team . I know I am blessed.After being a patient for 10 years I began to have chronic pain issues second to back pain .My first surgery led to a second and a third .I established that I would receive my pain meds from my PCP. I receive weekly massage , acupuncture
    and 6 months ago I began exercising lost wt and I see a psychologist twice a month . I see my PCP monthly to receive my prescriptions . I have never felt the need to see my records but know the route to do so .And yes I have knocked heads with a provider over medication. My surgeon who on my last visit said “you will be back it maybe 2weeks 6 months but you will need surgery again and you will be off your pain meds for 6 months before hand.” My PCP and myself are working as a team to see it does not happen any sooner than it needs too . Oh and I will have a different surgeon .

  5. BL at 6:00 pm

    There is usually a charge for medical records. Although federal law states that they arent to charfe more than the xost of copying, some states do if state laws hace not changed to reflect federal law. Under feder law an adminiistrative or search fee is not to be charged. Each state has their own laws governing the cost of medical records and how they are to be dealt with when a practice closes, the provider dies or moves.

    A provider doesnt have to correct edrorz. But, if they refuse, you can write a statement and have it entered into your records.

  6. Terri Lewis at 10:32 am

    Patients should regularly examine their records and keep current copies. It is important to note that depending on the filter used by the physician and the limitations of the EHR system itself, records may not completely reflect the patient’s appointment experience. It is not uncommon for the records to reflect an experience that is wholly different than the patient’s memory of the conversation.
    To correct or supplement records, patients can ask for patient notes of the conversation to be made a part of the record; to ask for permission to record the conversation; or for a person that the patient chooses (family member, friend, or advocate) to accompany the patient and participate as a note taker for the examination and conversation.
    If you are impaired by significant levels of pain, illness, or psychological distress during the course of the examination or routine visit, you may not be able to participate as fully as you might otherwise. This makes it important for you to be sure that your records accurately reflect your status at the time of the evaluation, the conversation and the examination that led to the resulting treatment recommendations.
    Everybody benefits when the working alliance between patient and provider is valued by both parties to treatment.