When I reflect back on the emphasis of the importance of accurate medical records that was embedded into my nascent physician mind as a medical student and house officer and as I read the repetitive useless information, erroneous entries and pages of useless cut and past repetitions and even fabrication of what transpired I cannot believe what the medical recored has become. So in some ways this is one of the saddest and most disillusioned blog entries I have ever posted. In some cases the medical record has been useless and misleading and often inaccurate garbage and certainly potentially capable of harming the patient and likely a fertile field for plaintiff attorneys.
I read the medical records ( fairly easily obtained through the clinic's patient portal). I read that the patient had a physical exam ( describing normal finding for various parts of this phantom exam which she never had). No one listened to heart or lungs. Reading the medical history I find that she was said to have hyperthyroidism ( she had hypo) said to be on Armour thyroid ( she is not) .Reading another orthopedics record ( again from the patient portal ) I learn that the summary sheet described the wrong leg bone as having the issue of concern i.e. tibia rather than femur.
A few years ago I read on my own colonoscopy report that my physical exam was normal. This was another phantom exam, this was being signed off by one of my former partners.
So would it be fair to describe this type things as publishing a false medical record or simply put lying. Court room scene. Doctor, your records on Mrs X indicate you performed a physical exam prior to her endoscopy?. Did you in fact do such an exam? Mrs X has testified that she did not have such an exam.
Do the physicians even know what is contained in the medical record that they sign? Is that any excuse if they sign the record?
Addendum: 2/8/18 Still more. Having a pacemaker in place I take part in a "remote interrogation" of the PM every three months.This includes a summary done by a PM tech at the PM center at a local hospital. Each report ends with "the patient had no complaints". At no step in this process has anyone ever asked me how I am doing.
addendum 5/6/18 After remote interrogations every 3 months for two and one half years,at last the technician actually asked me how I was doing and if I was having any problems.
Addendum 6/30/21 I write about further instances of phantom exams in as blog post about the Cures Act.