M E D I C A L _ R E C O R D S

In the state of Pennsylvania, you must be the patient, executor of the patient's will, or be authorized by one or the other in order to gain access to the patient's medical records. At least that's how I understand it. If you are representing a deceased loved one in a matter in which you suspect the doctor of incompetence, malpractice, or negligence; you will find yourself in the uncomfortable situation of wondering if the records will tell the truth. When it comes to medical record truth, most doctors have privileged access to it, and therefore have the ability to change history if they choose. Not only are you dealing with the tragic loss of a loved one, but you must also be a detective of sorts in dealing with medical records. Needless to say this should not be the case. It is an incredibly unfair advantage for doctors. It is the responsibility of the State of Pennsylvania to rectify this situation. The cost of the technology to accomplish this is at an all time low.

Dr. Barton's medical records consist of a compilation of individual patient charts on single 8 1/2" x 11" sheets of paper held together loosely in a folder. Also included in the folder are reports from medical laboratories, testing facilities, and consultations from medical specialist's etc. However, a typical patient chart is as shown below. The charts shown are as I received them except for the color highlights, which I added. Each chart is roughly structured into sections from the left side of the paper as follows, Subjective, Objective, Assessment, and Plan. The doctor's nurse conducts a preliminary interview with the patient and provides the subjective information. This is seen below in the area above the broken blue line on my mother's chart for January 7, 1997. As you can see from the chart, her handwriting is distinctly different from that of Dr. Barton. When Dr. Barton arrives, he breaks out the remaining portion of the chart into Objective (O), Assessment (A), and Plan (P) sections. On the chart below, within the Objective section, Dr. Barton has further divided that section into two subsections, one noted by the abbreviation ASHD, which stands for arteriosclerotic heart disease and addresses my mother's coronary artery disease (CAD); and the other DM, which stands for diabetes mellitus. The chart is dated (1-7-97) on the top left corner. As you can see the nurse noted the visit was routine, i.e. a regular quarterly visit. Also noted is the fact

that my mother is concerned because of shortness-of-breath (sob), and weakness on the left side of her body, both symptoms of coronary artery disease. I have placed two sets of brackets on the chart for illustrative purposes (1 green and 1 red). The green bracket includes Dr. Barton's notes in regard to my mother's coronary artery disease. The north arrow next to what I believe to be the word "angina" would indicate an increase in the intensity of her angina. His solution to the problem begins on the line below. He prescribes a Nitroderm patch, a patch laced with nitroglycerine in a dosage as prescribed on the following line. The line below that beginning with "T g ---------------" states the patch is to be worn during the day and removed at night. The last line in the ASHD section, the one in red brackets, is a referral to the Lebanon Cardiology Associates (LCA) for a Persantine Thallium Stress test. That's the test that would probably have saved my mother's life. The only problem is that it never took place, we were never billed for it, and LCA has no record of it.

There are only two possibilities that I can think of as to how the entry could have come about. One possibility was that the referral was intended, but somehow the finalization never took place. The other possibility is that the entry was made (altered) after the rest of the chart was completed. There are several problems with the first analogy. One problem is that my mother was never told of the referral. Is a referral a referral if you don't tell the patient? Even if the date and time were not firm when she left Dr. Barton's office, she should have known that a referral was in the making. Secondly, if a snafu had developed in the finalization of the referral, Dr. Barton would have been aware of it a month later when my mother came to him under a sense of urgency. Since the diagnosis had not changed, would it not then be logical to specify the Persantine Thallium Stress test along with the two improper tests on February 5, 1997?

As mentioned, my mother's next appointment with Dr. Barton took place a month later on February 5, 1997. Her chart for that appointment is shown below. Notice, this time the nurse did not describe this visit as routine. That's because my mother, under a sense of urgency concerned she might have a heart attack, came in on the date of my father's scheduled appointment asking Dr. Barton for help.  My mother once again complained to Dr. Barton's nurse of weakness and ankle edema (swelling in the ankle area), both symptoms of CAD. Dr. Barton's notes include the abbreviation DOE, dyspnea on exertion, or shortness of breath on walking. Her blood pressure was up as noted by the abbreviation

BP next to a north arrow indicator. In addition, Dr. Barton notes fluid retention. Dr. Barton finally decided to send her for cardiology tests. The tests he scheduled, however, a non-stress echo and a Holtor Monitor EKG, are not recommended for determining the presence or location of coronary artery disease. What's missing, of course, is the element of stress. Ischemia, a condition in which the need for oxygen exceeds the supply, does not manifest itself in some CAD patients unless under stress. That's why the exercise stress test has been a staple of routine physicals for many years. It's not a difficult concept to grasp, not even for the layman.

A Persantine Thallium Stress test would have been an appropriate test to schedule considering my mother's symptoms, complaints, and inability to exercise. If in fact one had been scheduled on 1-7-97 and a scheduling snafu had developed, Dr. Barton would have known about on February 5, 1997. It then would have been logical to schedule the Persantine Thallium Stress test on February 5 in addition to or in place of the non-stress echo and the Holtor Monitor EKG. That obviously did not happen which, in my opinion points to the probability that the implied January 7, 1997 referral was not entered on the chart until a later date. In addition, There is a reference on my mother's February 23, 1996 chart to a stress thallium test she allegedly had in 1992. She did not have that test either. It seems to me if that reference had been entered on the chart on 2/23/96, presumably with accuracy in mind, it would have been easy for Dr. Barton, to turn back about 20 pages of my mother's folder and verify that she did not have a stress thallium in 1992. What he referred her for in 1992 was the same combination of Holtor EKG / non-stress echo he prescribed in 1997. If he had asked my mother when she last had a stress thallium, she would not have known what he was talking about since she never had one. A stress thallium is an exercise test. My mother was unable to complete a standard exercise stress test in 1991. The erroneous entries on my mother's 2/23/96 and 1/7/97 charts were the only erroneous entries I was able to find on her charts going back to her first visit with Dr. Barton in 1983. They just happen to coincide with the two dates in which nitroglycerine was prescribed. It is my opinion based on the above observations that these entries were made on dates later than the dates on the charts. If any one can offer a logical alternative I will be most happy to incorporate that alternative on this page or add it elsewhere on this web site. My email address is rbachman@nbn.net.

Assuming Dr. Barton's medical records to be typical, it should be obvious how easy it would be to add to or rewrite one or more charts. That's all there is to it. It's my understanding that even if you have the authority to access certain medical records, a doctor does not have to provide them immediately. I've been told he or she may take 24 hours or longer to do so. That's plenty of time to make adjustments. A doctor may need to find someone to rewrite the portion written by the nurse, but that should not be very difficult. Since you and or your attorney would not have access to other patient's records, you would not be able to compare the handwriting of the individuals anyway. Even if you could, while you may suspect alteration, you would not likely be able to prove it. Handwriting analysis is subjective.

Typed medical records are even easier to change. I am not suggesting that all doctors alter medical records. I'm simply suggesting that because medical records are so easy to change, I suspect it happens more often than we'd like to believe. It makes me uncomfortable to know my doctor can distort the truth to protect himself at my expense, and very likely get away with it. We should all be concerned that the State of Pennsylvania is not looking for ways to eliminate this outrageous situation. The solution may not be very expensive in the long run. Medical records eventually end up stored at outside locations anyway. Why not transmit them electronically as soon as they are completed to organizations tasked with maintaining those records? Electronic and magnetic storage costs should be lower than the cost of storing paper. Medical records could then be retrieved from those firms directly without concerns about alteration. Medical records today are considered the property of doctors. That needs to change. Once individual patient charts are completed, they should be considered as public domain.

 

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