Dr. says 1 thing/chart says another

[Magali]

I need some perspective here. I realize this is such an insignificant issue, on the grand scale of things. But it is needling at me a little.

I asked my Dr. for a copy of my prenatal records. So I am looking at my records and I see that for my first BP reading she has written 140/88. This is odd to me because that is classified as "high". And I specifically remember her telling me it was 139/?? and "high but still normal". I know it is just one point, but it happens to be the point that puts me into the danger zone, yk? Perhaps it is normal for hcp's to round up? I'm not concerned about my BP. I have become obsessed with taking it at home and at machines all over town and I am always well within normal limits. But seeing it recorded as differently than what she told me it was, was weird.

And this past week at my prenatal, I specifically asked how my urine was. She said "fine". Then I asked...."so no protien in my urine?", and she told me "no". So now looking at my chart, it says +1 protien. I just wish she would have answered me correctly so we could have discussed it. Instead now I am wondering what the heck?

Would it bother you if your chart said different things (even if they are kinda minimal), than what you were told by your Dr?

[Mom2M]

Yes, it would bother me, I would definitely bring it up. I really think it is important that the chart reflects what the patient is told and what the results of exams and tests are. It has become more common for errors I think, in part because of the way the transcribing stuff is set up. There were glaring mistakes in my chart when I asked for a copy of my neurosurgeon's office notes, I wrote everything down and went over it and had it corrected. He said that sometimes if the dr doesn't check a certain box in the computer or something, the default answers will be transcribed.

[crunchy_mommy]

Yes... the minimal errors can add up or be indicative that she's more likely to make 'big' errors too... or if they aren't technically 'errors' she's misleading you with the verbal answers -- either way, I think it's a problem, and I would discuss it with her to find out what happened (it could just be that she records everything at the end of your appointments and all she remembered is that your BP was borderline or something, but even that explanation I'd wonder about...) These things can affect your care, or cause you to "risk out" of delievery options etc.

However if it's "after the fact" I guess I'd worry less (i.e. I saw some things in my hospital discharge paperwork after DS was born that I didn't agree with -- not sure if they were mistakes or false assumptions or what -- but I had no intention of seeing that OB again & we did not bring our records to our new doc, just verbally relayed the important info, so I didn't bother making an issue out of it).