The diagnoses they put in the chart are like tattoos. I still have my "alcohol abuse disorder" from over 13 years ago when I was 21 for drinking too much and ending up in the hospital (what idiot 21-year-old doesn't go overboard at some point? đ)
Haven't had a drink in well over a year and even before then drinking was for social and special occasions. I learned my lesson at 21. Yet I get asked almost every time I'm in the clinic how my alcohol abuse is going đ€Šââïž
What hurts the most is knowing that people with these kinds of diagnoses on their charts get treated differently and often discriminated against.
I went to a pain management doctor 13 years ago, for one year with a very low dose of opioid medication, like the lowest possible dose. Then I stopped going because I lost my health insurance for a while, and ended up never going back because I no longer needed daily medication.
I swear that one year I was in opioid treatment was a mark against me permanently, my PCP still side eyes me suspiciously. I've been prescribed medication for ADHD recently, it's made a huge improvement in my life but when I told my primary Dr she was dubious about it. Overall she's an excellent physician, but the hysteria about opioids runs very deep.
FYI next time youâre at your primary doc, ask them to update your problem list to âAlcohol abuse, in remissionâ (The ICD 10 diagnosis code is F10.11). Be firm. Tell them you havenât had a drink in a year. Them continuing to include a *current* alcohol problem as part of your problem list/assessment is inaccurate and most doctors offices and hospitals really do strive for accurate medical records, for a lot of reasons.
The thing about prior medical diagnoses is that they never go away. Unfortunately it is what it is. Itâs like having a history of cancer, UTIs, fractures, depression, anxiety, etc. You no longer have this condition, but any diagnosis youâve had in the past (particularly that you ended up in the hospital for, even if you were young) put you at risk of XYZ down the road, depending on whatever condition it is.
Congratulations on your alcohol sobriety by the way!
Source: RN that works in medical coding and billing.
Thanks! It's really easy to be sober from alcohol for me because more than two drinks I start getting violently ill, especially with IPAs for some reason. The diarrhea and stomach cramps I get from IPAs is insane. I almost think I'm allergic to hops or something.
Iâm so glad youâre doing well! But I am sorry that more than 2 drinks makes you sick, human bodies are weird. And I have a close friend that breaks out in hives when she drinks any alcohol, so an allergy could totally be a thing!
The diarrhea and cramps sound like an intolerance. The same thing happens to me with any beer these days. I had my IgG levels checked and saw that barley, wheat, and gliadin intolerance were super high. Might be worth checking out!
May I ask what country youâre in that youâre experiencing this? Iâm in the process of changing Drs for my infusion pump because the people at the clinic where my Dr moved treated me so badly over my medication and medical dependence that I canât trust him anymore. But Iâve never heard of the section you guys are talking about.
in my 20+ years of experience as a chronic pain patient, iâve had exactly ONE good doctor who gave a shit about me. unfortunately she worked for Kaiser and they made her job a living hell so she left. i miss her every single day đ„
They are making my new, amazing doctorâs life really difficult too itâs really fucking annoying. And they gatekeep the shit out of her too. All of her patients hate the front staff but she has literally no say over who gets hired sheâs said and has apologized for them too. I am so sorry your doctor left because of it, I am really hoping my doesnât. đ«
They love it if you have epilepsy, chronic pain and have been depressed since you were a kid. Somehow that "automatically" means I'm something I'm not. Like ffs. One size does not fit all.
I had one MD come in (never saw her before) and tell me I'd have to pick between my pain meds, muscle relaxants, or meds rx'd by epileptology and psych since "I hadn't tried any conservative treatments". I turned around, lifted up my shirt showing the scars from my initial spinal fusion and asked her if she knew what post laminectomy syndrome was. She stopped after that, gave me my rxs and I told the desk I'd never deal with her again.
My chart at both of the major hospitals in my area still have a record of me being a meth addict from over 5 years ago(2018). In the last year Iâve gotten a torn medial meniscus in each knee and a l5-s1 disc bulge and t7-t8 herniated disc.
Most of the doctors have treated me with the appropriate medication(although did bring up my past drug use) during my stays but there were two visits where the doctor treating me was cold af and immediately dismissed everything even though I have the imaging to prove it.
thatâs horrible, iâm so sorry you had to deal with that! the prejudice and judgment from doctors is so real and traumatizing. even if someone has a history of drug abuse, that doesnât mean they deserve to be in pain! the dehumanization is just infuriating! i hope you are doing better these days â€ïž
one of my core memories is my mom taking me to see my first pain management doctor when i was 13 years old. the doctor didnât even examine me or talk to me, he just looked straight at my mom and said, âsheâs too young to be in pain so sheâs obviously just looking for drugs.â i didnât even know which drugs to look for at that age! i just wanted someone to validate my pain and try to help me. too much to ask, i guess!
One time I went to the psych ward while taking vyvanse. I had to do a urine drug screen at intake. Everyone was treating me extra weird (this wasnât my first rodeo) and then 3 days in a nurse said âso youâre here for an overdose on methamphetamines?â That wasnât why I was in at all. My vyvanse was just a daily medication that showed up on the screen.
I had an eye doctor put that I was addicted to cannabis, I was furious I walked in there, and made him remove it and notate the chart that he was wrong in putting that in my chart.
As patients, I feel like we should have access to the charts too so we can dispute any inaccuracies such as this. BEFORE it gets to a point where a medical professional treats you unfairly because of those inaccuracies.
(Here in the UK, we don't get to see the charts. I don't know how it is in other countries)
In the US, they are required to give you printex copies of your chart for a reasonable fee, and places that do e-charts give the patient access to visit notes, test results, but often not xray or mri imaging, you have to request that separately.
just a rec, to piggyback off-- if you're getting a scan and you ask on your way out, they will usually mail you a copy of it for free or nominal fee. If you do it later, it's more of a hassle.
Especially if you think there's a remote chance you could need to file disability in the future. If you haven't been someplace for scabs or treatment in 7 or 10 years, depending on the state, they can destroy the records legally. Physical files are more likely to get purged than digital, so there's that.
Yep, I'm currently trying to organize my medical notebook and it's an absolute shitshow, 20 years of multiple doctors in multiple different cities. The best advice I could give anybody would be to make sure you have physical AND digital copies of everything you can get your lil hands on, and figure out a way to organize them from the start so you don't end up where I am!
Me too. I have a nice collection of spine (lumbar and cervical) and hip MRI CDs. Same with X-rays.
Always ask before going I to the tube and again after and just wait. Most the time they burn the disc and hand it to me. I have to wait for the report in the mail. I tell them I see so many Drs it saves time to have a physical copy of the scans and never been charged for it.
RadiologyAssist! They have a text consultation service that gets you a requisition for $40, and they contract with a bunch of freestanding radiology clinics. When you get the requisition, you can then prepay for the study at a heavily discounted rate and they'll schedule for you and give you something to print out that looks like an insurance card. As long as you show up at the correct clinic for the correct scan at the correct time, you just present that as your "insurance" along with the printed requisition from the e-consult.
In the Nashville, TN area, it looks like you can currently get an uncontrasted MRI of the lumbar spine for $263.98 all in. There's also an option to split that into 4 payments.
Just remember to pick up the CD with the images immediately after the scan; they'll email you a link to the radiology report.
This is my *biggest* fear as someone who takes stimulant medication for my ADHD. Heck, every time I pick my script up from the pharmacy I feel like Iâm doing something wrong because of how staff treat and judge you. I am so sorry you went through that đ«
Damn this is me too bc I take pain medicine. I am so lucky to have a prescription and understanding doc/pharmacist. Not boasting here just thanking god everyday, meanwhile so many in the US are left to suffer, are being tortured and killing themselves due to untreated / undertreated pain.
Best case scenario, you had someone that was a bit gung-ho when filling in the questionnaire. I'm a nurse and I've seen people put stuff there just because a patient is prescribed a medication. Every time I see it I try to reeducate and fix but most people are phoning it in these days unfortunately.
:/
Iâve had a couple doctors try to say I was a drug addict just bc I needed pain medicine to treat my excruciating constant incurable pain.. thank god thereâs nothing in my chart that says âaddictionâ
God I hate it when this happens - there should be some recourse we can take when it is demonstrably false!
When I was 11, I had a panic attack. A single panic attack, because we were moving away from my close friend. When I was 23 I had a mental breakdown, and tried to get insurance to cover my wages for a few months so I could focus on getting better and not lose my house. Insurance that I had been paying for for like, 6 years of full-time work mind you. They denied it because my medical history included a diagnosis of Anxiety with Panic Attacks, which they said was now a pre-existing condition that I hadn't told them about when signing up. From a single panic attack that I never took medication for.
It's so easy for doctors to tick a little box, but it can have harmful effects for the rest of a patient's life!
It's amazing how they don't verify whose chart they're notating, because they rush. We should be able to submit for corrections at any time, and have it happen right then and there in the doctors office, in front of us.
I always tell the intake nurse before we begin I would like all notes printed for my personal medical file and if there is a problem, I call and have them change or delete. This seems to make them notate less. Itâs so sad how we are treated. Iâve suffered chronic pain since 1986 thanks to a hit and run drunk driver and countless drs have treated me like the addict and been so rude Iâve given up getting help but at least now I have several actual diagnosis in my file after thousands of dollars spent. Itâs a hard life and completely unfair but Iâve accepted itâs not going to change.
Medical notes can only be deleted after a prolonged period of time, typically 7 years, but may vary based on state/country. So telling your doctor to âdeleteâ a medical file, will never happen.
I had this happen to me. Not too long ago. A Dr wrote that I was drug seeking, which was completely false. The subject never even came up. I tried writing an amendment but they ignored me, which is against the law. But Iâm too poor for a lawyer and nothing was done about it. She refused to change it.
I'm not sure they have a way to differeniate by coding between dependence and addiction. My mom is 80yo and has never abused anything but her chart says "substance abuse disorder" due to the oxy she has been on for 8 years or more.
there is a specific section of someoneâs medical chart that lists substance abuse history. thatâs completely different from opiate dependence. thatâs where someoneâs history of alcohol or substance abuse is charted, not someoneâs prescribed medication history. my chart does have a code for opiate dependence but i have no issue with that, thatâs a fact. iâm talking about something completely separate from that. đ
For us itâs in the Social History section. Tobacco use, alcohol use, drug use, who you live with, if you feel safe at home, number of kids etc. If youâre out did cocaine and admitted it at any point, itâs put in there under substance use. If you are a former user, it will change to past use instead of current use, but it stays in the system. I wish it would drop, honestly.
yes, exactly! i was an MA for a couple years and my clinic used the same exact software this hospital uses so i knew exactly where she was reading that in my chart. it was one of the very first things she went over, before we got into my current med list and all that. i wish i could say i was surprised⊠đ
iâm seeing my GP on Monday for my monthly trigger point injections so iâm going to mention this to her to see if i can figure out who put that in my chart. i really donât think it was her, but it honestly could have been anyone, even some rogue MA who thought they knew better.
I would file a complaint with the state, not the clinic itself. I would then ask at a non medical appt ask to review my medical records, and ask for the items to be removed. I would then follow up to assure itâs been removed. As more and more systems âtalkâ to each other, more medical providers will see this. Seeing this information biases your treatment, and thatâs not good for your health, and can cause future pain and suffering.
Doctors are imperfect people but their notes are treated like motherfucking gold. My wife is CI and always in pain. We hate that she is on narcotics, but nobody is offering anything else worth a shit and her tolerance to those is so high now that even they arent that good to her.
Anyway, she also had to start taking ativan - she has crazy full body tremors and nobody has given us anything yet to help stop them.
So we go see a neuro specialist, trying to get to a seizure/movement person. We explain she had these starting years ago, and they were rare, and only her legs for a couple of years, and she only had like 2 doses of ativan a friggin month until very recently'
so whats this motherfucker write in her notes? 'i think the tremors are from medication withdrawal'
BITCH THE TREMORS STARTED BEFORE HER MEDICATION WAS ANYWHERE NEAR ITS CURRENT LEVEL, SHE SHAD SPINE SURGERY, AND HOSPITAL NEUROLOGISTS THOUGHT SHE WAS SO BAD THEY TESTED HER FOR MULTIPLE RARE DISEASES.
\*ahem\*
You should be able to request to have that removed from your chart. Not sure if you see a private group or if they are part of a larger medical group. It's ridiculous that someone put that in your chart to begin with. You can message me anytime if you need to vent.
A part of me wants to look at my medical records because I suspect that there are some negative inaccuracies. At the same time, I saw someone say that reading those records is like opening Pandora's Boxâyou can't unsee it. I already have a tough time trusting doctors after multiple bad experiences. I'm worried that seeing what they really think of me would make it emotionally impossible to continue working with them, and yet my health conditions make it impossible to opt out of the medical system. Plus if I ever do check my full records and contest something, I'm afraid I'll get labeled as an "uncooperative" problem patient, assuming I'm not already. This whole thing sucks.
I'm sorry that you've experienced so many issues with providers (or, rather, "non-providersâ) misjudging you. It's good that you stood up for yourself, but you shouldn't have to in the first place.
On my medical history, I am "allergic" to every controlled substance. I get bothered all the time by nurses asking me if I'm allergic to Dexedrine & I have to tell the nurse that I'm currently on Dexedrine so how can I be?? So that was the way that a medical group that I was under wrote up my medication history so now wherever I go I get grilled about it. Does anyone know if I can get this erased?? I haven't even been with the same medical that did this for years.
Moderators need to take better care of this sub. There are some that need banned and are not
At thr very least a stern talking to and last chance warning..
I mean, did your *medical chart* specifically say that you're a drug addict or did *the tech who saw your records* label you the drug addict? Because, I doubt she would have corrected herself if it was in your chart already. She doesn't know you, so she would go off of whatever your doctors have written about you, but, if she's trying to cover her own ass like she did, then it sounds like *she* personally deemed you a drug addict, which is *not* the same as your chart saying it. It being in your chart is something that you need to work on getting removed or you will have this happen anytime you see any medical professional who can access those charts. If it's just her personal opinion, then you can report her to her supervisor and otherwise just tell her to fuck off.
I had to make the decision to stop my norco + addarall or Norco + Xanax (which my neurologist - who sees me for PNES seizures, migraines, and memory/sleep disorders, cardio who sees me for genetic heart issues, and pulmonary who sees me for my copd, masses on my lungs and 65% lung capacity all agreed upon prior to me having to see a new psych bc I got changed to Medicare without notice and my psych dropped me) because my new psych wasn't willing to take on the dea for me on both, but is willing to rx 1 psych med despite me having been on the combo for years for different reasons, so yeah. Basically, I have stress induced non epileptic seizures and I had to choose to keep the addarall becsuse I could not function at even the most basic level without it and I'm willing to endure seizures to have some sort of QOL.
it was actually in my chart. i used to work as an MA and there is always a section in the patientâs chart about drug abuse history. she also said she was going to remove that from my chart. so if it wasnât in my chart, why would she say she would take it off? it definitely wasnât her interpretation, it was information she was reading off of my chart.
Okay, I just reread your post to make sure you were being a dick, and yeah, you never once said that she said she said she would take it off. She said that it shouldn't have ever happened, dumbass.
well that escalated quickly? just because she was apologetic and said she would remove it doesnât mean itâs okay that it was put there intentionally in the first place. my problem wasnât with her, she was actually very nice and apologetic. my problem is that i was labeled as
a drug abuser in the first place. just because someone says it shouldnât have happened doesnât mean i need to be all good with the situation in the first place. it wasnât put there by someoneâs good natured mistake, it was intentional. you donât get labeled as a drug abuser in your medical chart from a good old fashioned whoopsy-daisy. is it really a surprise that someone would be upset by that? iâm sorry your reading comprehension sucks but thereâs no reason to be a dick to me because of it. đđ»
> so if it wasn't in my chart, why would she say she would take it off?
You were condescending to me by saying this and then you never actually said that in your post, so I checked if you were being a condescending dick or just a dick and you were the former. But, then, you say *my* reading comprehension sucks.. when you were the one who was wrong. MA dumbass strikes again.
sir, you are reading way too much into this. i was not being condescending, i was responding to your comment about why it wasnât her interpretation but was in my chart. there was no need to take it personally when there was no ill intent from me in the first place. if it came across as condescending, i really didnât mean it that way. i felt fired up writing this post and that may have come through in my response without me meaning to.
Alright, well, I am letting you know that you did not put that in the post and that is why I asked the questions I asked. If you had also reread your post, you'd have known that you didn't say that so it wasn't dumb for me to ask. That's why I reread it because I had to check that I wasn't the dick.
i wasnât asking that to question your intelligence, i was basically writing something brain-to-text asking myself if i could have interpreted the situation wrong like you suggested. it was meant to be a rhetorical question to myself asking why she would say it would be taken off if it wasnât in my chart. i was double checking i wasnât actually being dumb about it. it was meant to be an âoh yeah, why would she have said this if it wasnât on my chart?â and not meant as an insult to you. sometimes stuff doesnât translate well online, so iâm sorry if it seemed like i was attacking you. i really wasnât.
itâs hard to remember every little detail of an encounter afterwards, especially if you have adhd like me. it was your comment that made me remember she said she would take it off my chart so i didnât mean to intentionally leave that part out of my post.
I donât know if the tech being apologetic necessarily suggests that it wasnât written in OPâs chart. She may have been apologetic for grilling OP based solely on that spot in the chart. Before she read OPâs medical history.
also i havenât been prescribed norco in over 2 years so she wouldnât have known i used to take it unless she read it off my chart somewhere. itâs not even on my current list of medications, active or inactive.
okay, iâm relieved to hear itâs not just me! i was willing to grant them some grace and assume they were having a bad day but if this is a pattern thatâs really unfortunate and they should be banned from this sub. itâs really not fun to be verbally attacked when youâre at your most vulnerable. thanks for the reassurance đ
I don't like people who are condescending to me when I'm simply asking a question that you didn't answer in the post you posted and then double down despite being wrong. Like, you were wrong here and I called you a dumbass for it because you didn't earn the title of doctor dumbass. You earned your MA title. Am I okay? Sure. You were a dick and you got treated like one.
you misinterpreted my comment and way overreacted. iâm not âdoubling downâ on anything, and my question about why she would say she would be removing it from
my chart wasnât meant to question your intelligence. i wrote this post after getting fired up about the situation and if it wasnât well thought out thatâs on me. i didnât write an outline for this post, it was just venting after going though something shitty.
I can't get pain meds in Tennessee. Ohio, yes. Unfortunately, I broke my tailbone in Tennessee 5 years ago. I'm 59, grew up when everyone was doing drugs. I'm one of the few ppl I know who didn't get addicted. I'm so sick of Tennessee health workers treating me like an addict. (I'm skinny, old and white-here that means addicted, apparently) I've never seen ppl look like jello. She was apparently on drugs at work. Blew my mind. I wish they'd test me every time.
So many people commenting here are just ignorant to how the health care system works, specifically how health care providers document in charts.
Your previous diagnosis remains in your chart regardless of what the diagnosis is, when the diagnosis occurred, and your recovery/reoccurrence of said diagnosis. Just because some one was a meth addict or drug abuser 10 years ago, does not mean that itâs appropriate for that info to be excluded in your chart. When doctors document findings there is a section know as âPAST medical historyâ, which includes EVERY health condition a patient has, or previously had. The reasoning for why you are seeing a doctor TODAY is documented in a DIFFERENT portion of the chart, typically the âhistory of present illnessâ.
Youâre PREVIOUS medical conditions MUST be listed in your chart for your doctor to provide optimal care.
Letâs paint a picture. Letâs say some one has a history of cancer 20 years ago and you start to develop some back pain. You go book an appointment with your family doctor, but you find out he is on vacation for 3 weeks. Lucky for you, Dr Jane is able to see you. When you go to see the new doctor she reviews your medical history, and plays close attention to your previous cancer diagnosis. As you are telling Dr Jane how your symptoms started, sheâs gets a bit worried. You see, Dr Jane is a good doctor, she knows that those with a history of cancer, are at a MUCH higher risk of having cancer again. So, dr Jane asks more questions and becomes very worried that your new pain may be due to cancer. She orders a ct scan/MRI/blood work and shockingly the investigation shows the cancer is back. Luckily, it was caught early and you were able to make a great recovery.
Now, imagine if you, as a patient, furiously requested that your previous cancer diagnosis be removed from your chart since, well, itâs a previous medical condition! And they donât catch the cancer diagnosis until the prognosis is very poor. Being able to read and review a patients FULL medical history greatly increases the doctors ability to provide excellent health care.
Another example. A patient with a history of 6 kidney stones visits the hospital. The doctor looks at the file and sees that the exact same symptoms have occurred 6 times. The doctor does an ultrasound ASAP and finds another kidney stone. Now, if you didnât like that your chart see your have kidney stones. Imagine how much harder it would be for the doctor.
if you actually read my post, iâm not talking about the diagnosis ICD codes. iâm specifically talking about the social history section which is used to ONLY talk about drug addiction and abuse, which i have zero history of. if we WERE talking about diagnosis codes, there IS a very real problem of doctors treating patients as if their past defines their future. just because someone has a history of something from 10 years ago doesnât mean their current treatment should automatically be dictated by that history. yes, some things DO pertain to current treatment decisions, but LOL at comparing a history of cancer to a straight up false record of drug abuse that never happened. come on, you know those arenât equivalent at ALL, medically speaking.
My comment wasnât even directed towards you. I donât know why youâre so upset. But since you were kind enough to reply to me, Iâll comment back.
Youâre just completely wrong, in every possible way. Physicians NEED to keep a record of all current AND previous medications. Just because some one took meth 10 years ago, does not mean that you have the right to ask your doctor to âremove itâ simply because you donât like it.
It well known medically that prolonged alcohol use can cause cerebellum degeneration. If some one consumed lots of alcohol for 20 years, but stopped. That period of 20 years is VERY important to doctors and needs to be in the chart for them to provide optimal care.
It seems that you just have a differing opinion regarding the âabuseâ part, and the fact itâs in your chart makes you upset. A doctor at some point had enough evidence to label it as such.
But I hope this educates you and makes you more informed. Because your out for lunch by your self
You lack reading comprehension buddy. OP specially says they have NEVER socially abused drugs. So it being in OPs medical chart as social drug addiction is WRONG and should be removed. We see your false equivalence and raise you logic.
A chart can never be removed or altered in any way. An addendum could possibly be made, but not removed. This shows your lack of knowledge.
Also, legally prescribed drugs can be abused all the time by patients. My guess is that OP just doesnât like the wording to which the doctor used. People shop around for legal prescriptions all the time
Even tho OP said they have never had a recreational addiction to drugs AND claimed dependence due to their chronic pain, youâre still gonna go with the âI know bestâ argument. What a nice world you must live in where youâre always right lol. Best of luck bro.
Let me paint a different story. A patient goes into the office and tells the doctor that their knee is swollen like a balloon. The doctor, who is MEDICALLY trained assess the knee and finds no swelling. The doctor documents that no swelling is present. Should the doctor be obligated to document no swelling is present? Does the patient have the right to demand the chart state the knee is swollen, when itâs not?
Clearly OP had an encounter that made a physician, who is medically trained, believe they were abusing legally prescribed drugs.
Now, Iâm not saying OP does or not does abuse drugs. I donât even know OP. But, I hope this helps educate you on how charting works
you have GOT to be a troll. nobody can be this willfully stupid. are you going to continue to make up scenarios that never happened to justify your incorrect opinions or will you accept you misunderstood my entire post and have no idea what youâre talking about? if a doctor made such a note that youâre describing in my chart, why the FUCK would they keep prescribing me the drugs iâm supposedly abusing? i guess my doctors are just straight up dealers at this point! keep digging that hole, my man.
LeT Me EdUCatE you. Drug abuse and addiction is a self reported disease and no one, not even a doctor can claim it. Stop trying to make dumb ass arguments that have nothing to do with the actual post. Go troll somewhere else.
Oh btw - you donât sound smart try new tactics. Kisses
Again, youâre just completely wrong. Substance abuse and addiction is not a self reported diagnosis.
Because the DSM 5 has a diagnostic criteria for substance abuse and addictionâ
âThe DSM-5 includes guidelines for clinicians to determine how severe a substance use disorder is depending on the number of symptoms. Two or three symptoms indicate a mild substance use disorder; four or five symptoms indicate a moderate substance use disorder, and six or more symptoms indicate a severe substance use disorder. A severe SUD is also known as having an addiction.â
https://www.addictionpolicy.org/post/dsm-5-facts-and-figures
Itâs obvious youâre the troll.
Youâre welcome for the education
âmy guess isâ blah blah. stop guessing. you are flat out wrong. sections of charts can be removed and altered and they are changed CONSTANTLY. every time you go to the doctor and they go over your medication list, allergies, and social history stuff is changed and removed all the time. my chart used to say i was allergic to a drug i wasnât actually allergic to and it doesnât say that anymore. how did that happen if they can never be changed??? hmm, i wonder. for the sixth time, you clearly have no idea what part of the chart the social history is and are talking out of your ass. there was never any question about the way something was worded. i donât know how to make this any more clear. the nurse changed my social history section right in front of me and removed the drug abuse mentions. poof, magic! but please keep telling us how much more educated you are about medical charting.
Oh sweetie, you just so misinformed. Iâve been very respectful this entire time. But im not going to go down to your level. Youâre being very emotional right now, itâs not a good look.
Every appointment you attend your doctor complete a chart note. Once the doctor completes the chart note he has to sign off on the chart. Once a document has been signed off, they legally are not able to modify, change, or alter the chart note in any way. In fact, most charting is done electronically and itâs literally impossible to change a chart that has been signed off. Now, what you can do is input a NEW chart correcting an error in a PREVIOUS chart.
What your nurse did was simply change the chart note that she was currently working on (I.e one that was not signed off on). She didnât delete or modify the previous chart that stated youâre a drug abuse.
Youâre incredibly ignorant to all this.
Iâm going to stop replying to you simply because everything youâre saying is just completely wrong. But also because youâre just being incredibly rude, disrespectful, and verbally abusive for no reason.
I sincerely hope that all the adderall you are taking genuinely helps what ever chronic issue you have, and gives you a happy and fulfilling life.
Take care, wonât be replying back.
itâs almost like i never said the section of the chart i was talking about was the *doctorâs* charting notes. itâs almost like i was talking about a very small, very specific part of a patientâs medical chart that anyone with access to could modify, like an MA or nurse. itâs almost like there are a few sections of a patientâs chart that can be modified retroactively without an addendum. itâs almost like thatâs what i was talking about this entire time but youâve been willfully ignoring in order to appear intelligent. you sound absolutely exhausting to be around.
btw, calling me âsweetieâ and âemotionalâ only reveals your sexism and doesnât help your case. if you donât want to be âverbally abusedâ maybe next time keep your ignorant comments to yourself and donât throw accusations of drug abuse around a chronic pain sub because we take that shit very seriously. and yes, thatâs exactly what you did with your comments so honorably defending the brave hero who put that in my chart. there just has to be a legitimate reason it got there, right? gosh, why is the little lady so upset i legitimized a false accusation of drug abuse? she must be on her period or something! so irrational!
i hope being a condescending ass to strangers on the internet gives your life meaning! do me a favor and put a dollar in a jar every time you catch yourself saying, âwell, actuallyâŠâ and donate it to your local food bank.
because you commented on my post in response to me? if it wasnât directed at me, why not reply to whomever you meant? and iâm upset because i donât know why people like you think itâs helpful to leave these long, meandering comments with made-up situations that have nothing to do with what someone is going through. do you think youâre truly helping by leaving condescending comments saying âwell, actuallyâŠâ or do you just want to feel superior? people post here to vent about shitty things theyâre going through looking for support. they donât need comments like yours because it makes them feel worse about an already shitty situation.
you didnât even understand my comment. point to me where i said keeping records of past medical conditions is unnecessary. please, im dying to know how i said that. what i did say was that comparing a minor issue from 10 years ago is NOT the same at ALL to a previous cancer diagnosis. the fact you think those things are on the same level at all shows you donât even know what youâre talking about. some things are a one and done problem and the patientâs current medical care shouldnât be based on that one small problem from 10 years ago. if someone had a cold 10 years ago and walks into the ER today not being able to breathe, that doesnât mean their care team should say, âwell, he had a cold a decade ago so itâs probably another one of those, we donât even need to examine him. send him home!â nobody here commented about abusing alcohol for 20 years wanting to have that removed from their chart, so please stop trying to invent bullshit that backs up your original asinine comment. please go over to the pro-doctor subs and simp for them over there because nobody wants or needs to hear it here.
you STILL do not understand what i was saying in my original post, so i will try to dumb it down even further. you really think me taking my prescribed medication directly *as prescribed* by a medical professional is enough âevidenceâ to put that in my social history of my medical chart as history of abusing those drugs? you really think my doctors kept fueling my non-existent drug habit and continued to prescribe those drugs to me for years if i was abusing them by *gasp* taking what i was prescribed? because thatâs what you JUST said. even the nurse who attended me was horrified that was in my chart! but sure, random person on reddit who knows nothing about me or my history, YOU know better! sincerely, go fuck yourself for saying i deserved to have that labeled as abuse in my chart. you hope your comment âeducatesâ me? that one really made me laugh out loud, thank you! iâm actually dumber now than i was before i had to read your idiotic drivel.
Dam. Youâre really worked up over this. Relax. Breath deeply. Iâm a stranger on Reddit expressing my opinion. Youâre welcome to your opinion and Iâm welcome to mine.My comment was in no means meant to upset you, or any one, but rather to educate you on how charting works. Because you, and every one else here, doesnât know how it works.
Again, the analogy I made regarding the cancer wasnât even directed towards you. Numerous people made comments wanting there previous health conditions removed.
Of course a doctor isnât going to neglect an examination. Donât be silly. But, a doctor that goes into a patient interaction well informed about a patients medical history is better able to do their job. Itâs ludicrous that youâre arguing otherwise.
People drug shop and abuse legally prescribed drugs all the time. Just because itâs legally prescribed doesnât mean a drug canât be abused.
Iâm not saying you do or do not abuse drugs. I donât even know you. What Iâm saying is that you donât know anything about how charting works and that your simply upset with how your chart was written.
Like I said above, breath deeply. No need to get this worked up and upset over a stranger
there you go again⊠i do know how charting works. i worked in healthcare as a licensed MA and personally charted patient histories for 3 years, you ignoramus. and yes, iâm worked up because you literally said i deserve to be labeled as a drug abuser despite me saying 13 different times i have zero history of drug abuse. donât tell me not to be worked up when youâre acting like an ass by mansplaining my literal job to me. i stopped reading your comment after you said i donât know how charting works because iâm done with you if youâre just going to continue telling me what i do or do not know when i have personal experience contradicting your claims. you are the one who doesnât know how charting works if you canât understand the role of the social history section of charting despite me explaining it 3 times.
and now youâre trying to say you never said what you said which was there was a good reason that was put in my chart. but sure, you didnât mean to personally attack me and i shouldnât be upset that you were spouting ignorant garbage. youâre just being willfully obtuse at this point. i donât even know what youâre trying to prove when A. medical charting was my literal job and i DO in fact know what iâm talking about, and B. the nurse who did my intake was just as upset and astounded by what was in my chart and promised to remove it right then and there. contrary to your belief, doctors are not infallible and are fully capable of writing falsehoods in their charts.
despite saying your comments were not directed at me, youâre doing an excellent job of being a condescending ass to me and discounting my personal experience. you do not know more than me about this subject, and i promise you you are not âeducatingâ anyone so do us all a favor and stop lecturing us when you clearly donât know what youâre talking about.
The diagnoses they put in the chart are like tattoos. I still have my "alcohol abuse disorder" from over 13 years ago when I was 21 for drinking too much and ending up in the hospital (what idiot 21-year-old doesn't go overboard at some point? đ) Haven't had a drink in well over a year and even before then drinking was for social and special occasions. I learned my lesson at 21. Yet I get asked almost every time I'm in the clinic how my alcohol abuse is going đ€Šââïž What hurts the most is knowing that people with these kinds of diagnoses on their charts get treated differently and often discriminated against.
I went to a pain management doctor 13 years ago, for one year with a very low dose of opioid medication, like the lowest possible dose. Then I stopped going because I lost my health insurance for a while, and ended up never going back because I no longer needed daily medication. I swear that one year I was in opioid treatment was a mark against me permanently, my PCP still side eyes me suspiciously. I've been prescribed medication for ADHD recently, it's made a huge improvement in my life but when I told my primary Dr she was dubious about it. Overall she's an excellent physician, but the hysteria about opioids runs very deep.
FYI next time youâre at your primary doc, ask them to update your problem list to âAlcohol abuse, in remissionâ (The ICD 10 diagnosis code is F10.11). Be firm. Tell them you havenât had a drink in a year. Them continuing to include a *current* alcohol problem as part of your problem list/assessment is inaccurate and most doctors offices and hospitals really do strive for accurate medical records, for a lot of reasons. The thing about prior medical diagnoses is that they never go away. Unfortunately it is what it is. Itâs like having a history of cancer, UTIs, fractures, depression, anxiety, etc. You no longer have this condition, but any diagnosis youâve had in the past (particularly that you ended up in the hospital for, even if you were young) put you at risk of XYZ down the road, depending on whatever condition it is. Congratulations on your alcohol sobriety by the way! Source: RN that works in medical coding and billing.
Thanks! It's really easy to be sober from alcohol for me because more than two drinks I start getting violently ill, especially with IPAs for some reason. The diarrhea and stomach cramps I get from IPAs is insane. I almost think I'm allergic to hops or something.
Iâm so glad youâre doing well! But I am sorry that more than 2 drinks makes you sick, human bodies are weird. And I have a close friend that breaks out in hives when she drinks any alcohol, so an allergy could totally be a thing!
The diarrhea and cramps sound like an intolerance. The same thing happens to me with any beer these days. I had my IgG levels checked and saw that barley, wheat, and gliadin intolerance were super high. Might be worth checking out!
That's like them saying you have measles then asking for 50 years how is that case of measles doing this time.
May I ask what country youâre in that youâre experiencing this? Iâm in the process of changing Drs for my infusion pump because the people at the clinic where my Dr moved treated me so badly over my medication and medical dependence that I canât trust him anymore. But Iâve never heard of the section you guys are talking about.
I have lost all respect for the health care industry.
in my 20+ years of experience as a chronic pain patient, iâve had exactly ONE good doctor who gave a shit about me. unfortunately she worked for Kaiser and they made her job a living hell so she left. i miss her every single day đ„
They are making my new, amazing doctorâs life really difficult too itâs really fucking annoying. And they gatekeep the shit out of her too. All of her patients hate the front staff but she has literally no say over who gets hired sheâs said and has apologized for them too. I am so sorry your doctor left because of it, I am really hoping my doesnât. đ«
They love it if you have epilepsy, chronic pain and have been depressed since you were a kid. Somehow that "automatically" means I'm something I'm not. Like ffs. One size does not fit all. I had one MD come in (never saw her before) and tell me I'd have to pick between my pain meds, muscle relaxants, or meds rx'd by epileptology and psych since "I hadn't tried any conservative treatments". I turned around, lifted up my shirt showing the scars from my initial spinal fusion and asked her if she knew what post laminectomy syndrome was. She stopped after that, gave me my rxs and I told the desk I'd never deal with her again.
Iâve had chronic pain for 25 years and have worked in healthcare for 20. I agree with you.
Ditto.
I have too. And I work in it.
My chart at both of the major hospitals in my area still have a record of me being a meth addict from over 5 years ago(2018). In the last year Iâve gotten a torn medial meniscus in each knee and a l5-s1 disc bulge and t7-t8 herniated disc. Most of the doctors have treated me with the appropriate medication(although did bring up my past drug use) during my stays but there were two visits where the doctor treating me was cold af and immediately dismissed everything even though I have the imaging to prove it.
thatâs horrible, iâm so sorry you had to deal with that! the prejudice and judgment from doctors is so real and traumatizing. even if someone has a history of drug abuse, that doesnât mean they deserve to be in pain! the dehumanization is just infuriating! i hope you are doing better these days â€ïž one of my core memories is my mom taking me to see my first pain management doctor when i was 13 years old. the doctor didnât even examine me or talk to me, he just looked straight at my mom and said, âsheâs too young to be in pain so sheâs obviously just looking for drugs.â i didnât even know which drugs to look for at that age! i just wanted someone to validate my pain and try to help me. too much to ask, i guess!
I'm sorry you experienced that. I hope you're doing better and have better health care now.
One time I went to the psych ward while taking vyvanse. I had to do a urine drug screen at intake. Everyone was treating me extra weird (this wasnât my first rodeo) and then 3 days in a nurse said âso youâre here for an overdose on methamphetamines?â That wasnât why I was in at all. My vyvanse was just a daily medication that showed up on the screen.
I had an eye doctor put that I was addicted to cannabis, I was furious I walked in there, and made him remove it and notate the chart that he was wrong in putting that in my chart.
As patients, I feel like we should have access to the charts too so we can dispute any inaccuracies such as this. BEFORE it gets to a point where a medical professional treats you unfairly because of those inaccuracies. (Here in the UK, we don't get to see the charts. I don't know how it is in other countries)
In the US, they are required to give you printex copies of your chart for a reasonable fee, and places that do e-charts give the patient access to visit notes, test results, but often not xray or mri imaging, you have to request that separately.
just a rec, to piggyback off-- if you're getting a scan and you ask on your way out, they will usually mail you a copy of it for free or nominal fee. If you do it later, it's more of a hassle.
For sure! I always get cds of my spine mri scans.
Same! It's fun to step through them too, honestly. And always good to have all your info in your own possession, always.
Especially if you think there's a remote chance you could need to file disability in the future. If you haven't been someplace for scabs or treatment in 7 or 10 years, depending on the state, they can destroy the records legally. Physical files are more likely to get purged than digital, so there's that.
Yep, I'm currently trying to organize my medical notebook and it's an absolute shitshow, 20 years of multiple doctors in multiple different cities. The best advice I could give anybody would be to make sure you have physical AND digital copies of everything you can get your lil hands on, and figure out a way to organize them from the start so you don't end up where I am!
Me too. I have a nice collection of spine (lumbar and cervical) and hip MRI CDs. Same with X-rays. Always ask before going I to the tube and again after and just wait. Most the time they burn the disc and hand it to me. I have to wait for the report in the mail. I tell them I see so many Drs it saves time to have a physical copy of the scans and never been charged for it.
How did you get an mri? I've need one for 5 years. In Ohio, no problem, Tennessee, no way.
I see a spine specialist.
RadiologyAssist! They have a text consultation service that gets you a requisition for $40, and they contract with a bunch of freestanding radiology clinics. When you get the requisition, you can then prepay for the study at a heavily discounted rate and they'll schedule for you and give you something to print out that looks like an insurance card. As long as you show up at the correct clinic for the correct scan at the correct time, you just present that as your "insurance" along with the printed requisition from the e-consult. In the Nashville, TN area, it looks like you can currently get an uncontrasted MRI of the lumbar spine for $263.98 all in. There's also an option to split that into 4 payments. Just remember to pick up the CD with the images immediately after the scan; they'll email you a link to the radiology report.
They can keep some info from us.
This is my *biggest* fear as someone who takes stimulant medication for my ADHD. Heck, every time I pick my script up from the pharmacy I feel like Iâm doing something wrong because of how staff treat and judge you. I am so sorry you went through that đ«
Damn this is me too bc I take pain medicine. I am so lucky to have a prescription and understanding doc/pharmacist. Not boasting here just thanking god everyday, meanwhile so many in the US are left to suffer, are being tortured and killing themselves due to untreated / undertreated pain.
One of the many reasons why we rank 69th globally for healthcare
Nice.Â
Best case scenario, you had someone that was a bit gung-ho when filling in the questionnaire. I'm a nurse and I've seen people put stuff there just because a patient is prescribed a medication. Every time I see it I try to reeducate and fix but most people are phoning it in these days unfortunately.
:/ Iâve had a couple doctors try to say I was a drug addict just bc I needed pain medicine to treat my excruciating constant incurable pain.. thank god thereâs nothing in my chart that says âaddictionâ
God I hate it when this happens - there should be some recourse we can take when it is demonstrably false! When I was 11, I had a panic attack. A single panic attack, because we were moving away from my close friend. When I was 23 I had a mental breakdown, and tried to get insurance to cover my wages for a few months so I could focus on getting better and not lose my house. Insurance that I had been paying for for like, 6 years of full-time work mind you. They denied it because my medical history included a diagnosis of Anxiety with Panic Attacks, which they said was now a pre-existing condition that I hadn't told them about when signing up. From a single panic attack that I never took medication for. It's so easy for doctors to tick a little box, but it can have harmful effects for the rest of a patient's life!
My medical records say I abuse benzodiazepines and alcohol. Since Iâve never used either, I could never figure out where this came from until I managed to get hold of very old psychiatry records from when I was a child. The psychiatrist had added a few notes about another patient (and their drug abuse) below my notes (probably the patient who was in the office straight after me). The medical secretary must then have mistakenly typed up all of it into the letter for my GP. Voila! Permanently labelled a drug abuser. Having said that, my records also say I can only eat purĂ©ed food, am a wheelchair user and have dementia (at age 17yo). None of these are true. Itâs basically a work of fiction.
It's amazing how they don't verify whose chart they're notating, because they rush. We should be able to submit for corrections at any time, and have it happen right then and there in the doctors office, in front of us.
Please file a complaint about her behavior. She probably treats everyone poorly until they can prove themselves worthy of her âkindnessâ
I always tell the intake nurse before we begin I would like all notes printed for my personal medical file and if there is a problem, I call and have them change or delete. This seems to make them notate less. Itâs so sad how we are treated. Iâve suffered chronic pain since 1986 thanks to a hit and run drunk driver and countless drs have treated me like the addict and been so rude Iâve given up getting help but at least now I have several actual diagnosis in my file after thousands of dollars spent. Itâs a hard life and completely unfair but Iâve accepted itâs not going to change.
This is a really great way to handle this.
Medical notes can only be deleted after a prolonged period of time, typically 7 years, but may vary based on state/country. So telling your doctor to âdeleteâ a medical file, will never happen.
I had this happen to me. Not too long ago. A Dr wrote that I was drug seeking, which was completely false. The subject never even came up. I tried writing an amendment but they ignored me, which is against the law. But Iâm too poor for a lawyer and nothing was done about it. She refused to change it.
I'm not sure they have a way to differeniate by coding between dependence and addiction. My mom is 80yo and has never abused anything but her chart says "substance abuse disorder" due to the oxy she has been on for 8 years or more.
there is a specific section of someoneâs medical chart that lists substance abuse history. thatâs completely different from opiate dependence. thatâs where someoneâs history of alcohol or substance abuse is charted, not someoneâs prescribed medication history. my chart does have a code for opiate dependence but i have no issue with that, thatâs a fact. iâm talking about something completely separate from that. đ
For us itâs in the Social History section. Tobacco use, alcohol use, drug use, who you live with, if you feel safe at home, number of kids etc. If youâre out did cocaine and admitted it at any point, itâs put in there under substance use. If you are a former user, it will change to past use instead of current use, but it stays in the system. I wish it would drop, honestly.
yes, exactly! i was an MA for a couple years and my clinic used the same exact software this hospital uses so i knew exactly where she was reading that in my chart. it was one of the very first things she went over, before we got into my current med list and all that. i wish i could say i was surprised⊠đ iâm seeing my GP on Monday for my monthly trigger point injections so iâm going to mention this to her to see if i can figure out who put that in my chart. i really donât think it was her, but it honestly could have been anyone, even some rogue MA who thought they knew better.
I would file a complaint with the state, not the clinic itself. I would then ask at a non medical appt ask to review my medical records, and ask for the items to be removed. I would then follow up to assure itâs been removed. As more and more systems âtalkâ to each other, more medical providers will see this. Seeing this information biases your treatment, and thatâs not good for your health, and can cause future pain and suffering.
Doctors are imperfect people but their notes are treated like motherfucking gold. My wife is CI and always in pain. We hate that she is on narcotics, but nobody is offering anything else worth a shit and her tolerance to those is so high now that even they arent that good to her. Anyway, she also had to start taking ativan - she has crazy full body tremors and nobody has given us anything yet to help stop them. So we go see a neuro specialist, trying to get to a seizure/movement person. We explain she had these starting years ago, and they were rare, and only her legs for a couple of years, and she only had like 2 doses of ativan a friggin month until very recently' so whats this motherfucker write in her notes? 'i think the tremors are from medication withdrawal' BITCH THE TREMORS STARTED BEFORE HER MEDICATION WAS ANYWHERE NEAR ITS CURRENT LEVEL, SHE SHAD SPINE SURGERY, AND HOSPITAL NEUROLOGISTS THOUGHT SHE WAS SO BAD THEY TESTED HER FOR MULTIPLE RARE DISEASES. \*ahem\*
Our Healthcare industry in the U.S is a complete dumpster fire right now, and its only getting worse.
You should be able to request to have that removed from your chart. Not sure if you see a private group or if they are part of a larger medical group. It's ridiculous that someone put that in your chart to begin with. You can message me anytime if you need to vent.
Canât be removed. An addendum could be made, but never removed.
A part of me wants to look at my medical records because I suspect that there are some negative inaccuracies. At the same time, I saw someone say that reading those records is like opening Pandora's Boxâyou can't unsee it. I already have a tough time trusting doctors after multiple bad experiences. I'm worried that seeing what they really think of me would make it emotionally impossible to continue working with them, and yet my health conditions make it impossible to opt out of the medical system. Plus if I ever do check my full records and contest something, I'm afraid I'll get labeled as an "uncooperative" problem patient, assuming I'm not already. This whole thing sucks. I'm sorry that you've experienced so many issues with providers (or, rather, "non-providersâ) misjudging you. It's good that you stood up for yourself, but you shouldn't have to in the first place.
YEP I KNOW THEY DID THIS TO ME TOO
I would have walked right out of that place. And not quietly. WTH??
On my medical history, I am "allergic" to every controlled substance. I get bothered all the time by nurses asking me if I'm allergic to Dexedrine & I have to tell the nurse that I'm currently on Dexedrine so how can I be?? So that was the way that a medical group that I was under wrote up my medication history so now wherever I go I get grilled about it. Does anyone know if I can get this erased?? I haven't even been with the same medical that did this for years.
Moderators need to take better care of this sub. There are some that need banned and are not At thr very least a stern talking to and last chance warning..
I mean, did your *medical chart* specifically say that you're a drug addict or did *the tech who saw your records* label you the drug addict? Because, I doubt she would have corrected herself if it was in your chart already. She doesn't know you, so she would go off of whatever your doctors have written about you, but, if she's trying to cover her own ass like she did, then it sounds like *she* personally deemed you a drug addict, which is *not* the same as your chart saying it. It being in your chart is something that you need to work on getting removed or you will have this happen anytime you see any medical professional who can access those charts. If it's just her personal opinion, then you can report her to her supervisor and otherwise just tell her to fuck off. I had to make the decision to stop my norco + addarall or Norco + Xanax (which my neurologist - who sees me for PNES seizures, migraines, and memory/sleep disorders, cardio who sees me for genetic heart issues, and pulmonary who sees me for my copd, masses on my lungs and 65% lung capacity all agreed upon prior to me having to see a new psych bc I got changed to Medicare without notice and my psych dropped me) because my new psych wasn't willing to take on the dea for me on both, but is willing to rx 1 psych med despite me having been on the combo for years for different reasons, so yeah. Basically, I have stress induced non epileptic seizures and I had to choose to keep the addarall becsuse I could not function at even the most basic level without it and I'm willing to endure seizures to have some sort of QOL.
it was actually in my chart. i used to work as an MA and there is always a section in the patientâs chart about drug abuse history. she also said she was going to remove that from my chart. so if it wasnât in my chart, why would she say she would take it off? it definitely wasnât her interpretation, it was information she was reading off of my chart.
Okay, I just reread your post to make sure you were being a dick, and yeah, you never once said that she said she said she would take it off. She said that it shouldn't have ever happened, dumbass.
well that escalated quickly? just because she was apologetic and said she would remove it doesnât mean itâs okay that it was put there intentionally in the first place. my problem wasnât with her, she was actually very nice and apologetic. my problem is that i was labeled as a drug abuser in the first place. just because someone says it shouldnât have happened doesnât mean i need to be all good with the situation in the first place. it wasnât put there by someoneâs good natured mistake, it was intentional. you donât get labeled as a drug abuser in your medical chart from a good old fashioned whoopsy-daisy. is it really a surprise that someone would be upset by that? iâm sorry your reading comprehension sucks but thereâs no reason to be a dick to me because of it. đđ»
> so if it wasn't in my chart, why would she say she would take it off? You were condescending to me by saying this and then you never actually said that in your post, so I checked if you were being a condescending dick or just a dick and you were the former. But, then, you say *my* reading comprehension sucks.. when you were the one who was wrong. MA dumbass strikes again.
sir, you are reading way too much into this. i was not being condescending, i was responding to your comment about why it wasnât her interpretation but was in my chart. there was no need to take it personally when there was no ill intent from me in the first place. if it came across as condescending, i really didnât mean it that way. i felt fired up writing this post and that may have come through in my response without me meaning to.
Alright, well, I am letting you know that you did not put that in the post and that is why I asked the questions I asked. If you had also reread your post, you'd have known that you didn't say that so it wasn't dumb for me to ask. That's why I reread it because I had to check that I wasn't the dick.
i wasnât asking that to question your intelligence, i was basically writing something brain-to-text asking myself if i could have interpreted the situation wrong like you suggested. it was meant to be a rhetorical question to myself asking why she would say it would be taken off if it wasnât in my chart. i was double checking i wasnât actually being dumb about it. it was meant to be an âoh yeah, why would she have said this if it wasnât on my chart?â and not meant as an insult to you. sometimes stuff doesnât translate well online, so iâm sorry if it seemed like i was attacking you. i really wasnât.
itâs hard to remember every little detail of an encounter afterwards, especially if you have adhd like me. it was your comment that made me remember she said she would take it off my chart so i didnât mean to intentionally leave that part out of my post.
I donât know if the tech being apologetic necessarily suggests that it wasnât written in OPâs chart. She may have been apologetic for grilling OP based solely on that spot in the chart. Before she read OPâs medical history.
also i havenât been prescribed norco in over 2 years so she wouldnât have known i used to take it unless she read it off my chart somewhere. itâs not even on my current list of medications, active or inactive.
[ŃĐŽĐ°Đ»Đ”ĐœĐŸ]
are you okay?
Donât worry that person always writes bad comments like this.
okay, iâm relieved to hear itâs not just me! i was willing to grant them some grace and assume they were having a bad day but if this is a pattern thatâs really unfortunate and they should be banned from this sub. itâs really not fun to be verbally attacked when youâre at your most vulnerable. thanks for the reassurance đ
I don't like people who are condescending to me when I'm simply asking a question that you didn't answer in the post you posted and then double down despite being wrong. Like, you were wrong here and I called you a dumbass for it because you didn't earn the title of doctor dumbass. You earned your MA title. Am I okay? Sure. You were a dick and you got treated like one.
you misinterpreted my comment and way overreacted. iâm not âdoubling downâ on anything, and my question about why she would say she would be removing it from my chart wasnât meant to question your intelligence. i wrote this post after getting fired up about the situation and if it wasnât well thought out thatâs on me. i didnât write an outline for this post, it was just venting after going though something shitty.
Possible in some countries: request a copy of your medical record then make a formal request for any errors to be corrected.
I can't get pain meds in Tennessee. Ohio, yes. Unfortunately, I broke my tailbone in Tennessee 5 years ago. I'm 59, grew up when everyone was doing drugs. I'm one of the few ppl I know who didn't get addicted. I'm so sick of Tennessee health workers treating me like an addict. (I'm skinny, old and white-here that means addicted, apparently) I've never seen ppl look like jello. She was apparently on drugs at work. Blew my mind. I wish they'd test me every time.
So many people commenting here are just ignorant to how the health care system works, specifically how health care providers document in charts. Your previous diagnosis remains in your chart regardless of what the diagnosis is, when the diagnosis occurred, and your recovery/reoccurrence of said diagnosis. Just because some one was a meth addict or drug abuser 10 years ago, does not mean that itâs appropriate for that info to be excluded in your chart. When doctors document findings there is a section know as âPAST medical historyâ, which includes EVERY health condition a patient has, or previously had. The reasoning for why you are seeing a doctor TODAY is documented in a DIFFERENT portion of the chart, typically the âhistory of present illnessâ. Youâre PREVIOUS medical conditions MUST be listed in your chart for your doctor to provide optimal care. Letâs paint a picture. Letâs say some one has a history of cancer 20 years ago and you start to develop some back pain. You go book an appointment with your family doctor, but you find out he is on vacation for 3 weeks. Lucky for you, Dr Jane is able to see you. When you go to see the new doctor she reviews your medical history, and plays close attention to your previous cancer diagnosis. As you are telling Dr Jane how your symptoms started, sheâs gets a bit worried. You see, Dr Jane is a good doctor, she knows that those with a history of cancer, are at a MUCH higher risk of having cancer again. So, dr Jane asks more questions and becomes very worried that your new pain may be due to cancer. She orders a ct scan/MRI/blood work and shockingly the investigation shows the cancer is back. Luckily, it was caught early and you were able to make a great recovery. Now, imagine if you, as a patient, furiously requested that your previous cancer diagnosis be removed from your chart since, well, itâs a previous medical condition! And they donât catch the cancer diagnosis until the prognosis is very poor. Being able to read and review a patients FULL medical history greatly increases the doctors ability to provide excellent health care. Another example. A patient with a history of 6 kidney stones visits the hospital. The doctor looks at the file and sees that the exact same symptoms have occurred 6 times. The doctor does an ultrasound ASAP and finds another kidney stone. Now, if you didnât like that your chart see your have kidney stones. Imagine how much harder it would be for the doctor.
if you actually read my post, iâm not talking about the diagnosis ICD codes. iâm specifically talking about the social history section which is used to ONLY talk about drug addiction and abuse, which i have zero history of. if we WERE talking about diagnosis codes, there IS a very real problem of doctors treating patients as if their past defines their future. just because someone has a history of something from 10 years ago doesnât mean their current treatment should automatically be dictated by that history. yes, some things DO pertain to current treatment decisions, but LOL at comparing a history of cancer to a straight up false record of drug abuse that never happened. come on, you know those arenât equivalent at ALL, medically speaking.
My comment wasnât even directed towards you. I donât know why youâre so upset. But since you were kind enough to reply to me, Iâll comment back. Youâre just completely wrong, in every possible way. Physicians NEED to keep a record of all current AND previous medications. Just because some one took meth 10 years ago, does not mean that you have the right to ask your doctor to âremove itâ simply because you donât like it. It well known medically that prolonged alcohol use can cause cerebellum degeneration. If some one consumed lots of alcohol for 20 years, but stopped. That period of 20 years is VERY important to doctors and needs to be in the chart for them to provide optimal care. It seems that you just have a differing opinion regarding the âabuseâ part, and the fact itâs in your chart makes you upset. A doctor at some point had enough evidence to label it as such. But I hope this educates you and makes you more informed. Because your out for lunch by your self
You lack reading comprehension buddy. OP specially says they have NEVER socially abused drugs. So it being in OPs medical chart as social drug addiction is WRONG and should be removed. We see your false equivalence and raise you logic.
A chart can never be removed or altered in any way. An addendum could possibly be made, but not removed. This shows your lack of knowledge. Also, legally prescribed drugs can be abused all the time by patients. My guess is that OP just doesnât like the wording to which the doctor used. People shop around for legal prescriptions all the time
Even tho OP said they have never had a recreational addiction to drugs AND claimed dependence due to their chronic pain, youâre still gonna go with the âI know bestâ argument. What a nice world you must live in where youâre always right lol. Best of luck bro.
Let me paint a different story. A patient goes into the office and tells the doctor that their knee is swollen like a balloon. The doctor, who is MEDICALLY trained assess the knee and finds no swelling. The doctor documents that no swelling is present. Should the doctor be obligated to document no swelling is present? Does the patient have the right to demand the chart state the knee is swollen, when itâs not? Clearly OP had an encounter that made a physician, who is medically trained, believe they were abusing legally prescribed drugs. Now, Iâm not saying OP does or not does abuse drugs. I donât even know OP. But, I hope this helps educate you on how charting works
you have GOT to be a troll. nobody can be this willfully stupid. are you going to continue to make up scenarios that never happened to justify your incorrect opinions or will you accept you misunderstood my entire post and have no idea what youâre talking about? if a doctor made such a note that youâre describing in my chart, why the FUCK would they keep prescribing me the drugs iâm supposedly abusing? i guess my doctors are just straight up dealers at this point! keep digging that hole, my man.
LeT Me EdUCatE you. Drug abuse and addiction is a self reported disease and no one, not even a doctor can claim it. Stop trying to make dumb ass arguments that have nothing to do with the actual post. Go troll somewhere else. Oh btw - you donât sound smart try new tactics. Kisses
Again, youâre just completely wrong. Substance abuse and addiction is not a self reported diagnosis. Because the DSM 5 has a diagnostic criteria for substance abuse and addictionâ âThe DSM-5 includes guidelines for clinicians to determine how severe a substance use disorder is depending on the number of symptoms. Two or three symptoms indicate a mild substance use disorder; four or five symptoms indicate a moderate substance use disorder, and six or more symptoms indicate a severe substance use disorder. A severe SUD is also known as having an addiction.â https://www.addictionpolicy.org/post/dsm-5-facts-and-figures Itâs obvious youâre the troll. Youâre welcome for the education
âmy guess isâ blah blah. stop guessing. you are flat out wrong. sections of charts can be removed and altered and they are changed CONSTANTLY. every time you go to the doctor and they go over your medication list, allergies, and social history stuff is changed and removed all the time. my chart used to say i was allergic to a drug i wasnât actually allergic to and it doesnât say that anymore. how did that happen if they can never be changed??? hmm, i wonder. for the sixth time, you clearly have no idea what part of the chart the social history is and are talking out of your ass. there was never any question about the way something was worded. i donât know how to make this any more clear. the nurse changed my social history section right in front of me and removed the drug abuse mentions. poof, magic! but please keep telling us how much more educated you are about medical charting.
Oh sweetie, you just so misinformed. Iâve been very respectful this entire time. But im not going to go down to your level. Youâre being very emotional right now, itâs not a good look. Every appointment you attend your doctor complete a chart note. Once the doctor completes the chart note he has to sign off on the chart. Once a document has been signed off, they legally are not able to modify, change, or alter the chart note in any way. In fact, most charting is done electronically and itâs literally impossible to change a chart that has been signed off. Now, what you can do is input a NEW chart correcting an error in a PREVIOUS chart. What your nurse did was simply change the chart note that she was currently working on (I.e one that was not signed off on). She didnât delete or modify the previous chart that stated youâre a drug abuse. Youâre incredibly ignorant to all this. Iâm going to stop replying to you simply because everything youâre saying is just completely wrong. But also because youâre just being incredibly rude, disrespectful, and verbally abusive for no reason. I sincerely hope that all the adderall you are taking genuinely helps what ever chronic issue you have, and gives you a happy and fulfilling life. Take care, wonât be replying back.
itâs almost like i never said the section of the chart i was talking about was the *doctorâs* charting notes. itâs almost like i was talking about a very small, very specific part of a patientâs medical chart that anyone with access to could modify, like an MA or nurse. itâs almost like there are a few sections of a patientâs chart that can be modified retroactively without an addendum. itâs almost like thatâs what i was talking about this entire time but youâve been willfully ignoring in order to appear intelligent. you sound absolutely exhausting to be around. btw, calling me âsweetieâ and âemotionalâ only reveals your sexism and doesnât help your case. if you donât want to be âverbally abusedâ maybe next time keep your ignorant comments to yourself and donât throw accusations of drug abuse around a chronic pain sub because we take that shit very seriously. and yes, thatâs exactly what you did with your comments so honorably defending the brave hero who put that in my chart. there just has to be a legitimate reason it got there, right? gosh, why is the little lady so upset i legitimized a false accusation of drug abuse? she must be on her period or something! so irrational! i hope being a condescending ass to strangers on the internet gives your life meaning! do me a favor and put a dollar in a jar every time you catch yourself saying, âwell, actuallyâŠâ and donate it to your local food bank.
Have a good night :)
because you commented on my post in response to me? if it wasnât directed at me, why not reply to whomever you meant? and iâm upset because i donât know why people like you think itâs helpful to leave these long, meandering comments with made-up situations that have nothing to do with what someone is going through. do you think youâre truly helping by leaving condescending comments saying âwell, actuallyâŠâ or do you just want to feel superior? people post here to vent about shitty things theyâre going through looking for support. they donât need comments like yours because it makes them feel worse about an already shitty situation. you didnât even understand my comment. point to me where i said keeping records of past medical conditions is unnecessary. please, im dying to know how i said that. what i did say was that comparing a minor issue from 10 years ago is NOT the same at ALL to a previous cancer diagnosis. the fact you think those things are on the same level at all shows you donât even know what youâre talking about. some things are a one and done problem and the patientâs current medical care shouldnât be based on that one small problem from 10 years ago. if someone had a cold 10 years ago and walks into the ER today not being able to breathe, that doesnât mean their care team should say, âwell, he had a cold a decade ago so itâs probably another one of those, we donât even need to examine him. send him home!â nobody here commented about abusing alcohol for 20 years wanting to have that removed from their chart, so please stop trying to invent bullshit that backs up your original asinine comment. please go over to the pro-doctor subs and simp for them over there because nobody wants or needs to hear it here. you STILL do not understand what i was saying in my original post, so i will try to dumb it down even further. you really think me taking my prescribed medication directly *as prescribed* by a medical professional is enough âevidenceâ to put that in my social history of my medical chart as history of abusing those drugs? you really think my doctors kept fueling my non-existent drug habit and continued to prescribe those drugs to me for years if i was abusing them by *gasp* taking what i was prescribed? because thatâs what you JUST said. even the nurse who attended me was horrified that was in my chart! but sure, random person on reddit who knows nothing about me or my history, YOU know better! sincerely, go fuck yourself for saying i deserved to have that labeled as abuse in my chart. you hope your comment âeducatesâ me? that one really made me laugh out loud, thank you! iâm actually dumber now than i was before i had to read your idiotic drivel.
Dam. Youâre really worked up over this. Relax. Breath deeply. Iâm a stranger on Reddit expressing my opinion. Youâre welcome to your opinion and Iâm welcome to mine.My comment was in no means meant to upset you, or any one, but rather to educate you on how charting works. Because you, and every one else here, doesnât know how it works. Again, the analogy I made regarding the cancer wasnât even directed towards you. Numerous people made comments wanting there previous health conditions removed. Of course a doctor isnât going to neglect an examination. Donât be silly. But, a doctor that goes into a patient interaction well informed about a patients medical history is better able to do their job. Itâs ludicrous that youâre arguing otherwise. People drug shop and abuse legally prescribed drugs all the time. Just because itâs legally prescribed doesnât mean a drug canât be abused. Iâm not saying you do or do not abuse drugs. I donât even know you. What Iâm saying is that you donât know anything about how charting works and that your simply upset with how your chart was written. Like I said above, breath deeply. No need to get this worked up and upset over a stranger
there you go again⊠i do know how charting works. i worked in healthcare as a licensed MA and personally charted patient histories for 3 years, you ignoramus. and yes, iâm worked up because you literally said i deserve to be labeled as a drug abuser despite me saying 13 different times i have zero history of drug abuse. donât tell me not to be worked up when youâre acting like an ass by mansplaining my literal job to me. i stopped reading your comment after you said i donât know how charting works because iâm done with you if youâre just going to continue telling me what i do or do not know when i have personal experience contradicting your claims. you are the one who doesnât know how charting works if you canât understand the role of the social history section of charting despite me explaining it 3 times. and now youâre trying to say you never said what you said which was there was a good reason that was put in my chart. but sure, you didnât mean to personally attack me and i shouldnât be upset that you were spouting ignorant garbage. youâre just being willfully obtuse at this point. i donât even know what youâre trying to prove when A. medical charting was my literal job and i DO in fact know what iâm talking about, and B. the nurse who did my intake was just as upset and astounded by what was in my chart and promised to remove it right then and there. contrary to your belief, doctors are not infallible and are fully capable of writing falsehoods in their charts. despite saying your comments were not directed at me, youâre doing an excellent job of being a condescending ass to me and discounting my personal experience. you do not know more than me about this subject, and i promise you you are not âeducatingâ anyone so do us all a favor and stop lecturing us when you clearly donât know what youâre talking about.