Medical Records

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mistoferin -> Medical Records (7/20/2006 9:58:56 PM)
During my recent stay in the hospital I had something occur that was pretty serious that seemed to be caused by a mistake. I was having a PICC line inserted and when they went to flush it, it caused me instant distress. They thought that I was going into cardiac arrest and my room suddenly filled with alot of people. I was having severe "pressure" in my chest, difficult breathing and pain radiated up into my jaw and down my arm. Apparently I turned bright red and began sweating profusely. They immediately gave me an aspirin and hooked me up to an EKG. Then they took an X-ray and a few minutes later the PICC line team came back in and told me they had to move the line because apparently it was in too far and had "tickled" my heart. Well today I went to pick up my medical records for insurance purposes and was surprised that there was no mention whatsoever of this event to be found. No EKG report...nothing. So I'm wondering, for those who work in hospitals...is it common for such a significant event to not be documented? Could it be that someone has purged my records of a mistake?

maybemaybenot -> RE: Medical Records (7/20/2006 10:15:55 PM)
Hi Erin: I don't know if it is common, but I had a similar experience. Years back, when I was being worked up for a medical condition, I had a pelvic and adb CT Scan as an outpatient. I was called by the radiologist and told he had made an appointment for me with a Gyn oncologist. When I asked what the CT showed he was evasive and muttered something about a mass. Now, near hysterical and screaming, I demanded he read me the results. All I recall to this day is his last words words.... " consistant with metastic carcinoma of the uterus ". Thankfully, he read my CT scan wrong. But when I requested my medical records to give to my primary care MD and Gyn MD.. the CT Scan report was changed. No mention of mass, no mention of metastic carcinoma. Interestinly enough, it said I had a probable fibriod cyst on the apex of my uterus. Which after days of testing by the Gyn Oncologist, was the diagnosis she gave me. I suspect it happens more often than any of us realize. mbmbn edited to add: before anyone suggest or claims medical malpractice or neglect, neither erins nor my case fit the criteria for malpractice.Which are : The MD/healthcare pratitioner did not meet the standard of care. Proof of damages or injury and proof of what extent your injuries are greater because of the substandard care. All three conditions must be met. Which is one reason I wonder why this happens, besides the purely unethical side of it, which is more of a concern to me.

irishbynature -> RE: Medical Records (7/21/2006 4:40:08 AM)
quote: ORIGINAL: mistoferin During my recent stay in the hospital I had something occur that was pretty serious that seemed to be caused by a mistake. I was having a PICC line inserted and when they went to flush it, it caused me instant distress. They thought that I was going into cardiac arrest and my room suddenly filled with alot of people. I was having severe "pressure" in my chest, difficult breathing and pain radiated up into my jaw and down my arm. Apparently I turned bright red and began sweating profusely. They immediately gave me an aspirin and hooked me up to an EKG. Then they took an X-ray and a few minutes later the PICC line team came back in and told me they had to move the line because apparently it was in too far and had "tickled" my heart. Well today I went to pick up my medical records for insurance purposes and was surprised that there was no mention whatsoever of this event to be found. No EKG report...nothing. So I'm wondering, for those who work in hospitals...is it common for such a significant event to not be documented? Could it be that someone has purged my records of a mistake? It sounds like the Docs made an error in your treatment that unfortuately caused a bad reaction for you (I hope you're OK now!) Sometimes, they will 'flush' those records, as if they never happened...to avoid a lawsuit and cover up their mishap....I worked in Medical Records in College....saw that happen a few times. Best of luck! Irishbynature

diamonddreamlove -> RE: Medical Records (7/21/2006 7:12:41 AM)
Have heard where a local mental health facility (good informant and i worked there at the time as well) told me that the computer records of a suicide were well hidden within a computer system with the intent that if the company was sued they could destroy or bring out the records as they choose. Was also told that was a standard practice so i should make sure anything that serious was documented by me and kept separate. I believe it happened since my source was the contract computer specialist that found the hidden stuff. Anyway it is important to get the records ASAP with the idea someone might screw up the hiding process after you have your copies. Is sad to have to be so careful today to protect yourself but the larger medical organizations tend to make it necessary.

sub4hire -> RE: Medical Records (7/21/2006 7:29:27 AM)
I've never actually worked in a hospital, well I have but it was during my internship. At that point and time I would have been taught to record everything. So, yes it would have been on your records. However, stepping back to the other side of the coin. Dealings with my own family and I've had a lot. I do know as other's have said a lot disappears. LOTS. I assume it is for the same reason for fear of malpractice.

sublizzie -> RE: Medical Records (7/21/2006 7:34:56 AM)
What did you request in your medical record copies? Usually you have to request specific things to be copied and that is all that is copied. Medical record departments tend to be very particular about what they send out of the hospital so they are sticklers for only copying exactly what is requested.

mistoferin -> RE: Medical Records (7/21/2006 7:56:05 AM)
Well, when I realized that there was no documentation of this event, I asked the girl to please go back through and see if she could find any. Nurses notes....anything at all. She came back to tell me that none could be found. Now I am wondering what exactly to do. I have an upcoming surgery and will need another PICC line. The girl who did it explained to me that PICC lines are placed by a calculation of measurements that are taken externally. Apparently my internal measurements don't coincide with the external ones. I would have liked to be able to refer them to the notes of that event when it comes time to do the next one so that the mistake doesn't get repeated. Also, while I don't know for sure I would think that any such event involving the heart would be an important piece of information for any future doctors following my care. Not everyone is automatically thinking lawsuit...sometimes our health is the paramount concern.

mistoferin -> RE: Medical Records (7/21/2006 8:30:02 AM)
I am fairly certain that there had to be documentation initially. So does anyone know...is there some way to uncover it or is it simply gone for good? Would talking to the administration of the hospital be helpful or do you think I would just be spinning my wheels?

proudsub -> RE: Medical Records (7/21/2006 12:43:50 PM)
I had the opposite problem, I wanted something removed from my record and they wouldn't do it. When i left my first dom he was so upset and jealous that he told me he had herpes, so i went to get checked and later he admitted it was all a lie so that i wouldn't be with anyone else. My doc wouldn't take it off my record that i had talked to him about this, even though i didn't even have a test or exam.[:o]

YourhandMyAss -> RE: Medical Records (7/21/2006 1:09:49 PM)
hmm.

sublizzie -> RE: Medical Records (7/21/2006 1:15:28 PM)
If you are going to be having your procedure done in a different facility, just tell them about what happened. Getting medical records from other facilities takes a long time. Your version will go into your chart and be there for whomever is involved in your care during that hospital visit. You can also check with the doctors who were providing care during the previous hospitalization and see if they have any record of what happened. They may have something in their notes. It's also possible that the notations weren't completed by the time you went to get copies of your records. Sometimes they aren't done as quickly as they are supposed to be. Also, sometimes things are not filed in charts as quickly as they should be. It's possible the information just hadn't found it's way into your chart yet. I wish you well on your procedure. I understand wanting good, quality health care!

maybemaybenot -> RE: Medical Records (7/21/2006 3:21:59 PM)
erin: Did they give you your X Ray results? You had a Chest X-ray after the initial insertion to confirm placement. Which actually confirmed misplacement. Then when they retracted they did another chest X Ray. If you have copies of these records, it will indicate your anatomy difference. If they did not, I only have one other suggestion. Call the Radiology department of the hospital, the reports could be buried there. You can ask for copies of your Chest X Rays only or for copies of all X Rays. The chest X ray will be the most valuable test to have in regards to another PICC Line placement. Radiology departments in most, if not all hospitals are stored on disc nowadays. As for the EKG, it has no significance to the next PICC line placement, but I too would want the record. Maybe try a call to the Cardiac Lab of the hospital. I should have thought of this last night, but I was tired and my brain apparently turned off on it's own.. LOL.. Good Luck ! mia

BlkTallFullfig -> RE: Medical Records (7/21/2006 6:43:14 PM)
The event should have been documented in your medical records, and a good hospital would have that as well as a consent form saying this is among the possible adverse events to occur when you undergo an invasive procedure of this type... I've never seen/heard of that happening with a pic though; must have been pretty far in. M

JP719 -> RE: Medical Records (7/21/2006 7:32:00 PM)
When I was in the hospital after a work-related incident I had a reaction to the fluid they injected for the CT scan. This went in my medical record. Later on during that stay I had some X-rays that were unrelated to the accident and the results of this didn't show up on the hospital records....but it did show up on the insurance report, they weren't going to leave out anything.

mistoferin -> RE: Medical Records (7/21/2006 9:18:21 PM)
You're such a genius! I went through them again and found that they did give me a copy of the post placement X-ray report. It says "There is a right sided PICC line which is seen crossing the midline into the left brachiocephalic vein. It has to be pulled back and it's tip repositioned. Follow up is recommended". It also says that there is "ectasia of the thoracic aorta" which I have no idea what that is...but you can bet I'll be asking my doc about it. I am sure that this will be pertinent info that I can direct them to in the event of another PICC line insertion. Thanks!

maybemaybenot -> RE: Medical Records (7/21/2006 9:30:21 PM)
I am glad I could be of help, erin. Now your mind can rest a bit. ecstacia means "distended". So for some reason your thoracic aorta is puffed out. It could be from the placement of the PICC line.< most likely case scenario> I would also follow up on that with my MD. BTW.. the thoracic aorta is simply a section of the aorta, not a differnt vessel. mbmbn

Termyn8or -> RE: Medical Records (7/26/2006 9:20:50 PM)
Now, I just don't understand why they removed it the first time. All they needed to do is back it off a bit no ? Was it that far off target ? To the other poster who mentioned Xrays, this will not show up. Xrays chiefly show bone mass. The organs in the body are poorly reproduced. If you want to see that you need a tomography, such as a CAT scan. They may now be able to do it with ultrasound as well. Anyone's internal organs can be in a slightly different position. Not by all that much, but sometimes not all that much is too much. Actually I think it's a bit foolhardy to try to insert something so invasive as a PICC without something. They should be able to see and at least say "Look, this patient's heart is 2.5 mm occipital from the norm". Something like that. I simply will say nothing about incompetence here, this thread is not for that, the OP didn't ask for that so I am not going into it. There are other threads for that, but.... To get really specific to the actual question posed : I think there is a distinct possibility that because the PICC installation was rejected, and they could not then implement it's use, they may be barred from charging for it. That may explain it not showing up on the bill, but I certainly agree that such an adverse reaction should be noted in your records. Who would benefit from the removal of those records ? I wouldn't go back to that hospital. T

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