Is it really that hard to listen?

General
1

I have been stating for the last umpteen years that I feel like crap. Currently, I am dealing with headaches, dizziness, numbness and tinglinging on left side, baack pain, neck pain, pleurisy, scoliosis, spinal stenosis, spondylosis, trouble walking, brain fog, blurry vision, anemia, pain when sitting, pain when walking, pain when laying down, trouble sleeping, and a lot more that I can't think of right now etc.

Why in the heck did the neurosurgeon that was supposed to do my surgery on 3/12 only mention headache, back pain, neck pain, dizziness, and floaters in my medical records?

When I send this in for my SSI appeal, this is going to make it look like I am a liar because he is basically saying I am not that bad off because I should get back with him when I make my mind up about surgery. Yes, I saw him back on 11/20, but I set a date of 3/12 to bypass the snow and ice. So, I faxed a letter teing them which changes needed to be made to my file because it was wayyyy off. Hopefully, the changes can be made without me coming in for a visit.

Doctors really get on my nerves !!!!!!!!!!

Take care,

Nykki

2

Bring a printed copy of your medical records, including, but not limited to, surgical history, family history, medical history, current medications, allergies, and symptoms.

You can talk all you want. The MD is looking for your symptoms as they relate to the diagnosis they are exploring. It's not a matter of not listening. It's a matter of not having the proper links in the electronic medical records(EMR) mandated by Obama Care. The idea of EMR is great. The implementation is not optimal(and varied, there are >100 types of EMRs, most of which don't speak with each other, so imagine the Beta vs VHS battle x 100).

If that documentation is important to you(and it should be), bring your own printed copy(and keep a digital file, so you can update it regularly). Give it to the office(usually a medical assistant, not the MD) and ask it to be scanned into your medical records. It will help the care giver and the patient. Then, if your MD doesn't know your symptoms, a red flag should definitely go up. Most MDs will appreciate the effort you put in.

I used to e-mail all my patients their notes, so they could review them, ask any questions that may come up later, and confirm that what I heard is what they meant. I'm not longer able to do that with the new health care laws(actually, I should rephrase that, I can still do it, I just will pay a penalty to the government because "meaningful" use requirements prevent the use of natural language).

I agree it's frustrating but there are always work-arounds. You've seen enough MDs Nykki. The truth is, no one cares about your medical records as much as you do. If you included your symptoms in the faxed letter, simply ask them to scan it into your records. Win-win there.

As an aside, I always recommend patient keep digital records of their images as well(NOT the readings only, but a disc with the actual images).

I'm sure they can work with you to make the records reflect the correct issues.

3

Almost everything we have is digital now, so those binders of paperwork are slowly going away(like the old X-rays that we put on view boxes).

Your medical record will be digital in almost every MDs office already. Any paperwork you bring in, the office can scan in and make it part of your records(really ideal for situations like you describe, where the MD only documents a few symptoms(because that's either all that's coded into the EMR or that's all they bothered with) but the list of symptoms is much longer(and would make a difference to a disability adjuster but maybe not the surgeon).

This is one of many reasons I've tried to be digital for years. The more data we have in the patient's words, the more accurate we are.

Many offices don't scan the patient data into the chart(your digital file) unless asked, so they sit in a paper chart, or, even worse, get thrown out when the patient leaves. It is another step for the medical assistant but not a big deal and helps you get better documentation.

4 inches of paperwork is honestly too much, our eyes start to glaze over. We should have the medical stuff(X-ray readings, office notes, operative notes). Your clinical summary(mentioning in 1 sentence each operation or imaging done, but focusing on your current symptoms and treatment) will help focus the MD on what your primary concern is(and that should be no more than 3 pages and should ideally be scanned into your records). Think of it as your medical resume.

Hope that helped!