My OB did not dictate operating room records for my c-section?

[MamieCole]

I recently found out that the hospital where I had DS is closing, so I called today to request a copy of my medical records. I had a natural birth planned that ended up in a very traumatic c-section in sept. 206 and I am just now getting to the point where I am forgiving myself. Anyway...it is not a pleasant memory.

The person I spoke with was very nice and asked if I wanted all of the records or just portions. I told him I definately wanted all the records from the time I was admitted through the delivery and that it was important to me that the sugery report be included. He pulled up my records and said "Hmmm...that's odd. There is no OR report. There is just a one-page handwritten summary that she did upon your discharge. Looks like your doctore didn't dictate an OR report." At first he thought from the records that I didn't even have a c-section because of the lack of OR records.

WTH??? I asked if she could do legally that and he said "I guess she can. Looks like she didn't dictate anything about the c-section. There is just this one page summary that is handwritten and it doesn't include any OR specifics."

The operation portion of my birth was the one part that I have had the hardest time coming to closure with and now I have NO DETAILS. No specifics on what type of suture she used, no idea how long I was on the table....NOTHING. Is that legal? Do I have any recourse? I mean, other than calling her and giving her a piece of my mind, can I report her?

I am just so sad and frustrated right now, not to mention angry. Any advice?

[texmati]

I'm sorry... I don't have any advice, but it makes me so angry when doctors cut corners.

I hope that you have some legal recourse!

[Night_Nurse]

Where I currently work, the Operating Report isn't on a standard type dictated page like it was at other hospitals I worked. And it could be that a c-section op. report isn't on a page such as if you went to the same hosp. and had heart surgery. I only mention this as the person in med. rec. may not be familiar with where the c-sec. op. report would be if he was looking for a formal dictated noted. I hope that makes some since. It wouldn't hurt to call and ask someone else there in med. rec. (someone was assembles charts) if they know what section that report would be in. Or maybe you could call L&D and ask, as they look at those charts all the time. I find it hard to believe the doctor wouldn't write or dictate some sort of operating report (now maybe he/she did and it was mis-filed in someone else's chart).

Another thing to do would be to call the office of the MD that did the surgery. I believe they always get a copy of both your hospital record and their dictation. They might be able to help if the hospital can not.

[fairygirl13]

sometimes the hosptial does not keep that info, because they dont get it. usually when they dictate, they call in to a voice mail system, or put it on a recorder, and some person gets it, and is responsible for typing it up and sending it back. so it could be at the doc's office, or in another part of the hosptial, also, if he was looking on a computer, it might not be in there since it would not be written on the computer, it would have to be scaned in or saved in as a file. it might just be printed and thrown in a file that has your name that the computer person cant get ahold of.
as far as do they HAVE to do it? YES. under the medical practice act, all 50 states and teratories must have compliete and accurate documentation, each state has their own and may say it different, but yes they do. also the AMA says they do.

[Storm Bride]

Originally Posted by Night_Nurse

Another thing to do would be to call the office of the MD that did the surgery. I believe they always get a copy of both your hospital record and their dictation. They might be able to help if the hospital can not.

I'd do this, too. It's always possible that this is just a file management issue. The OR report may have been misfiled (anybody can put something in the wrong file) or never sent to where it's supposed to be. It may have been pulled at some point for some reason, and never put back into the file. It kind of makes me wonder that the clerk said the OB must not have dictated a report at all, because there are lots of other ways it could have gone missing.

[applejuice]

Looks like someone "doctored" up your records.

There has to be a record somewhere.

[MamieCole]

Thanks for the advice and support...I have taken a deep breath and trying to think positive that they are there. I live out of state, so am having my friend/doula pick up the records this week and she is going to mail them to me. Hospital said they could fax them but couldn't mail them. So, it'll be another couple weeks before I actually have them in my hand. I will try to think positive til then. Now I am going to try to get my mind on something else since there is nothing I can do about it at the moment. Thanks mamas!