Absolutely not the case. Hospitals have oversight bodies and third parties for almost EVERY incident, even down to patient complaints. Healthcare isn’t taken lightly in the U.S.
@@michaelscott33 my grandpa died because the hospital left a pic line in him for several months. It kept growing bacteria and his body just gave out. A nurse told us about it. She wasn’t supposed to. We asked doctors involved in his healthcare about it and all we got was a “I don’t know what you’re talking” about response. Eventually one of them acknowledged it, but it never showed up in any chart or records. By the time it was taken out, his body just couldn’t fight anymore and he died days later. No lawyer would take the case because it was the hospitals word against ours. I have no doubt that many hospitals will investigate. The problem comes with doctors who willingly lie. Falsified medical records happened with my Father-in-law and my grandpa. It didn’t kill my father-in-law, but it made his prostate cancer get treated YEARS later than it should.
@@michaelscott33 That may be true to some degree, but the system fails in practice. Patients end up having to sue to get any Justice because hospitals and their staff don’t want to admit they’ve done anything wrong. What you think they’re going to have someone evaluate how badly you’ve been hurt and just give you a pot of money?
I caught a medical practice trying to bill for services they didn’t provide during a birth. Fortunately, the medical records reflected that their staff was never in the room, at any time. I was fortunate to remember, and ask the question. It was a “mistake”. Sure it was.
That does happen when staff gets sloppy and things don’t get taken out of the computer like they should so at the end of the stay when things get billed out Susie in the office doesn’t know it wasn’t done
my mom was charged this really expensive medicine four times when she only took two of the things. it was a "mistake" if my mom didn't caught it she would have paid double
@@medoyk637As someone who has had to go after hospitals over changing medical records to get away with screw ups, I sure can. I’ve had the wrong guy in detainment because the hospital lied, (medical staff tested the wrong person then lied and said they tested the right one). This has happened so many times, I now get a person tested at least at two different facilities that are unaffiliated. Wait that about sums it up, hospitals will change things or leave things out that caused harm. I’ve had some wild situations where if these people were not needed medical staff(makes them more important than a few patients), they would be in jail for the things they cover up.
@@medoyk637 overdosing the patient on certain medications and treatments for example. A chart gets mixed up so two people get the wrong thing. For example a person I know died twice during surgery, this person was never told nor was the second time they died written down in the medical history. They only found out after they sued the hospital for something else that happened while they were there in the hospital recovering
@agsystems8220 what's really annoying is that one of them came with their assistant to introduce themselves so I'd "know everyone who was working on me today."
Anesthesia isn’t more expensive if multiple anesthesiologists signed onto your case. You may see a total for each, but it would add up to the total of only 1 anesthesiologist for 1 case.
Isn’t that odd. I just had cataract surgery with a nurse anesthetist on standby in the room just in case. But there were two claims filed. One for her and one for an anesthesiologist that was in the building but not in the OR.
Had a teacher who would collect homework in packets of 5. She lost two of my packets (two weeks worth of work) and said I didn't do them & reduced my class grade 10 points that marking period. 😡 Got a 98 (out of 99+) on my Regents (state given) test. Which qualified me for the honors class next semester, that's a tragedy for another time. 🙃
Had college visiting teacher post final, screw with my grade claiming I didn't turn in an assignment (which would have required me to retake a class) I produced the assignment turned in via email. Department head accused me of academic misconduct and started the process to kick me out of college and remove my progress. I challenged by contacting the Dean and the IT department. IT found the exact day and time that I had previously sent the assignment. Dean had the department put all the data back including the tampered grade. Never spoke with the Department head again.
My daughter is blind in one eye after back surgery. We know that the Drs fought over who needed to see her because we were there with her 100% of the time, it was a mess. Neurology, Opthalmology, so on. The doctors would tell us that they're trying to to get Dr so and so but he doesn't want to consult because it doesn't look like it's they're problem. Eventually the blindness in one eye reached the point where it was complete. We transfer hospitals, find out that it's not likely to come back but there's some things they can try, so we do it, and unfortunately it doesn't help. A couple months later we look into a suit, hospitals fight us and lawyer on providing records. Once we finally get them, it's the total opposite of what happened. All the specialists came and went. Performing tests and exams that they never actually did. Now lawyer tells us "but the records say they did and it's your word against theirs". So now my daughter is blind in one eye, has a back full of metal, and it just makes us cry seeing her totally transformed from a bright happy girl to being self conscious about her eye and giving up dancing that she's done all her life. All because Doctors did a shit job then lied about it.
@@IridescentW Do you think the hospital administration changed every individual doctor record to match together? Or do you believe every doctor coordinated with each other to change the records? I believe the former. Ipso facto, hospital administrations suck, while the doctors do not.
you could still follow with the suit, you would need a record specialist to understand the records and see if that specialist could find flaws in them. it can be easy to find if they created really fast. For example, a test is signed off by a worker but the other hospital records show that worker was not working that day. Can did this test happened when the person who signed off on it wasn't at work that day? Who did the test? Secondly, even if others believe the records, explain why your daughter still have a black eye? what is the likely hood that the treatment that they claim they did would not work? what dod they do / talk to when they noticed that the treatment they claim they did wasn't working? Why didn't they consult an outside specialist at any point? During the suit, you / your lawyer can ask each person who claimed to treat your daughter tons of questions. Such as, when they noticed the black eye, what days, what did they do about it, etc. all you need is for them to give contradictory statements either both the records or what the other people did. example, Dr A says he noticed it on day X but Dr B says he noticed it on day Y but day Y is before Dr A stated he told Dr B about the Eye when dr B told dr A he didn't notice it. If they knew on the same day, why are they stating the dates to be different? also if neither Day X or Y is the date listed in the file. If you noticed it on date X, why did it take to day Z to write it down? Could still be a hard case to win depending on these factors, but it doesn't take much to show the records and statements don't add up.
Worked on medical record software. They ABSOLUTELY audit every change, who did it, and when. If they're not giving you that information, they're withholding it.
So true. My father-in-law’s dad died of prostate cancer and when my father-in-law had elevated PSA numbers, his doctor blew him off for years as the number climbed. My mother-in-law blew her top and insisted on getting test and seeing a specialist. FIL ended up having cancer. The medical records sent to the cancer center indicated that my MIL had brushed off the doctor and his concern for the numbers and refused any further investigation. According to the records, it was the doctor that stood up to my MIL and insisted on testing. Apparently my father-in-law was just a bystander. Medical professionals will lie to get out of trouble and have no problem falsifying records.
I have actually witnessed forgery of physician signatures. I have seen dates on medical records where neither the physician nor the patient were even in the hospital.
I remember when I had oral surgery when I was 10 they couldn't find the problem that was on the X-rays, when my grandfather went to the dentist to get the original X-rays to give to the oral surgeon the dentist magically lost all the files. My grandfather had all his children change dentists that day
I was in the hospital for 2 nights a while back. I got into the room around 3pm, so I asked my wife to bring me my cpap device and mask, which I need to sleep. When I got the bill for the stay, there was an $800x2 charge for CPAP / breathing therapy. NOBODY ever talked to me about the cpap or did any breathing therapy. When I challenged it, the hospital said that they had provided the service. I asked for names of the therapists, test results and my cpap device settings…. Then asked again… then asked again. He fourth time I asked, they graciously comped me the $1600.
Dad had an employee that ended up in a medically induced coma for months. (Nearly fatal infection raging throughout his body.) His wife took time off of her job to essentially live in the hospital with him to guard him. She learned the SOP for his care and also learned about all of the different medicines that may be used. Some medications could not be used together. Some medications were ones that he himself could not have. She developed a curiosity, and then a routine, of always tracking what was being given to her husband. Most of the staff admired that he had such a strong advocate and didn't mind. Unfortunately, not all of the staff. One of the staff didn't check in with her, and instead just walked up to the patient to immediately add a syringe to the IV bag. On principle, the wife was upset; but she also felt strong internal alarm bells go off. She hollered out to stop. She tried to overcome her anger and adrenaline. She tried to stay polite. She had noticed that the person had not double checked the chart before administering a drug. She asked what it was. Again, the wife had to consciously overcome an instinctive desire to scream and attack. Instead, she told the person to wait and pushed the button for more help. The wife didn't trust herself around this person. Had that drug been administered, our friend would have been dead in minutes. It's been decades since this event. Specific details are no longer in my memory. But I can still viscerally remember how his wife was crashing off adrenaline and rage, and how panicked that ICU staff was after the fact. It cemented for me how important it is to have a main advocate; and to even create a schedule of friends, family, teammates, coworkers, etc to rotate a bedside vigil so that patients don't have to be alone. Hospital staff, no matter how professional they are, get busy and make mistakes, and/or forget that they can't take out a stressful day on the patient in the bed.
This could not happen without serious negligence or malice. There are protocols in place to prevent administration of a medication not belonging to the patient. Meds have to be removed from a central dispenser called an Omnicell for each patient. Before the order from the prescriber is approved and the medication available to be dispensed from the Omnicell, the pharmacist must verify it. Then the med is programmed into the Omnicell for that specific patient. The nurse then checks for any contraindications and removes it from the Omnicell. Then the patient must be scanned, the med must be scanned and the order accepted in the computer at bedside. At this point, the medication has been verified, the patient has been verified and the nurse can then administer the medication. Additionally, medications aren't added to a bag at bedside - ever. If a med is to be given by IV, the fluids are paused, the IV detached, the line is flushed, the med given per protocol outlined above, then the line is flushed again before reattaching the fluids and restarting the pump.
@@CraftHarlot Did it ever occur to you that statistics of cases like our friend is *WHY* all of the safeguards are in place now? BTW, don't be cocky about that list of safeguards. People are still given the wrong medications.
@@CraftHarlot the person said this happened decades ago. Omnicell, scanning bracelets, etc. wouldn't have been a thing then. I had my oldest child 18 years ago and there were just handwritten paper bracelets inside plastic.
A friend's baby died during birth. The midwife failed to detect fetal heartbeat several times, but didn't call an ambulance until it was too late. She later falsified the records, showing her recording the heart beat while the call logs showed she was talking to a consultant at the time.
People don’t like your comment, but It needs to be higher. Ask any paramedic or EMT what they fear, and it is childbirth. Sure, if everything goes perfect it is going to be fine. But the risks for women are not low. They are high. Modern medicine has made child birth extremely safe. But modern medicine means being in a hospital. Not your house.
Fortunately I live in a country where people give birth in hospitals, with a doctor in the room, because we are not mentally stuck in the 18th century and we know giving birth at home or under a tree is a stupid idea. And that's why our infant mortality is less than half compared the USA. In other words, baby born in the USA is more than twice as likely to die in childbirth. than here. It was already safer to give birth here than in the USA 20 years ago, when we were still a developing country.
@@neverstopschweiking Even just having midwives for at home births better regulated makes it a safer situation. At home births are riskier in the US because there are people practicing as midwives when they are not qualified and get away with it until tragedy happens (at least we hope they don't get away with it).
So true! For my Sister’s birth, the Obstetrician didn’t show for the entire birth and when my mother stood up to go get him because my father was grabbing a nurse, my sister came out… my father managed to get back in time to grab my sister before she hit the floor while the nurse had to grab my mother. She (mother) ended up with 3rd degree tears amongst other things from the birth. Apparently, the hospital just so happened to “lose” her medical records just after the surgery for her injuries… -_- Edit: 1. They went private for the doctor, so she paid this guy $5000 for him to no-show, 3. She also lost 1/3rd of her bowel. The main reason for the damage was that they didn’t turn the head during the birth so the shoulders “ripped her to shreads” (quote by mum), 4. Furthermore, 5 days after the birth, right before discharge, they asked if she had passed a motion (the answer was no). They ended up giving her charcoal, then a pill to get her to, which led to convulsions down there… As you could imagine, giving the damage and the amount of stitches she had, it was VERY painful. 5. This was in Aus
Where was this, Mexico? You do understand that “losing” medical records is more of a problem for the hospital than anything you wrote in your story here, which I do find hard to believe. Furthermore, per hospital policy your mother would have been at fault if the baby had hit the floor. Women who are about to give birth are ordered strict bed rest unless supervised. I find this story very difficult to believe on its merit alone. -infectious disease and critical care physician.
Those of us take pride in our work jump at the chance. We are often doing what other should’ve done and taking up the slack. It’s frustrating when others don’t do their job and any chance to correct this is great.
I worked in hospitals for over 30 years, starting as a clerk and ending as a health professional. When I started all charts were paper. Charting had to be physically continuous on the paper, I.e., nurse signs off from day shift, overnight nurse signs on on the next line. It would have been almost impossible for someone to change a note after the fact as there physically wasn't any space you could use. If a nurse made an error, she would have to cross out the error, write ERROR above it, initial and date it, and show it to the charge nurse. It was obvious. But with electronic records, as a patient you're at the mercy of the programmers, who I'm certain were never drilled on the sanctity, if you will, of medical records. If the software doesn't keep an audit record, you're out of luck, my friend. And the people overseeing the acquisition of the electronic chart system, wouldn't know what an audit trail was if it reared up and bit them.
Maybe 20 yrs ago when my drs were just getting into digital records, I was sent a link to mine that was actually for another patient with a name not at all similar to mine. Oops. Didn’t look at them but did call the records center to tell them, they were surprised, worried, thanked me profusely, and got on it right away. I don’t trust digital records but have resigned myself to the inevitability of them.
@@SicFromTheKushreading comprehension clearly isn’t your strong suite. Paper can be harder to fraudulently change, because at the very least, an audit system EXISTED. Coders, on the other hand, might not have understood the importance of tracking minute changes, hence, programs MIGHT NOT EVEN HAVE ANY audit system.
I worked in med rec 15yrs. I wish everyone took it as serious as I did cause they are not always complete or accurate. Then some docs refuse to do addendum once an issue is brought up. Some thanked me for catching issues though. I felt bad for patients who relied on these recs.
Huh? I’m a physician and have no idea what you’re talking about. Med Rec is when we take the patient’s home medications and reconcile them with what we have in their medical chart to ensure they’re getting accurate medications. There is no place to make an “addendum” even if a correction is needed. The med rec is SUPPOSED to be completed by the nurse and pharmacist, but I always end up doing it because the system fails the patient and the nurses are so ego-driven it’s beyond them to take a second to reconcile the meds. However, when they actually do reconcile them in the computer, it’s typically just them pressing “submit” and not even checking if they’re correct. It sickens me and pisses me off. I was a nurse for 10 years prior to becoming a physician and I’m starting to really have hatred for my old profession.
When i had baby #5 she was taken to the NICU following nurses observing what they believed to be seizure activity. Seizure activity in a newborn is a very big deal. I was recovering from a C-section and, thank God, had my husband to assist me going to the NICU to spend time with my newborn. Overnight and for one day my husband was unable to be present and during that time a nurse of mine decided she was going to manipulate the way she followed doctors orders because she personally believed i should be taking narcotic pain killers for at least three days following my C-section. I had already discussed with my doctor, and explained to her, that i wanted to be off any narcotic or opioid medications as soon as possible, that i had done well in the past with a Tylenol-Ibuprofen rotation with the medications taken simultaneously, then gradually spacing out. I was on narcotic pain medication for either 2 or 3 days, I'm still not sure which, and had a lot of trouble knowing how much time was passing. I was supposed to be caring for my newborn during this time, and with her in the NICU I needed to be pumping every two hours to establish milk supply. The narcotics stunted my milk coming in for days. Luckily my milk came in, i was okay, baby was okay, and my night nurse realized what happened, advocated for me, and raised hell behind the scenes. But this person is absolutely not crazy
"Pumping" is NOT the same as pure breastfeeding. There are hormones involved from both mother & baby which are necessary to establish & maintain b/feeding.
When my daughter was born, I basically wrote a book the first night in the hospital to journal that day and what the experience was like because I wanted to remember what labor was like when our kids are grown. And when I say I wrote a book, I mean, it’s a How I Met Your Mother level of detail. I documented every single conversation down to the word, every single thing I experienced down to the texture of the hospital chair, and every single thing I saw and heard down to cars I passed on the road. I literally wrote down everything I could remember. And after seeing this, I’m willing to bet my notes were probably more accurate than the nurses there considering they do that job every day and I was shooting for accuracy for the sake of my own memory. I kind of had more at stake because having your first child is a once in a lifetime experience, and I wanted more than anything to remember everything.
I would bet it was as or more accurate than what the nurses wrote...they have to look after multiple patients and then document while you sit in a chair and document
Also the nurse, housekeeper, doc and any staff that walked in could care less about 99% of what you wrote. They are only concerned about their task and what they are going to cook for dinner. Most of our tasks are auto tracked with a official timestamp.
That's so true. When medical records are requested (here usually by an insurance), the hospital will go over them with a lawyer and make sure everything is correct. A friend had a case where she requested the record just for her own interest (legal right here), and the requested record was in great detail. But some things were blatantly wrong. Something along the lines of "baby healthy" and some more descriptions. And actually the baby had some issues, icterus or similar and had been treated. Clearly a faked record and some data added with a different pen. Ridiculous.
I am a physician and medical admin - What you are claiming here is blatantly false and ABSOLUTELY illegal beyond belief. You are talking about a hospital committing federal crimes. No one would dare change the medical record, because the moment a change is made after the fact it draws suspicion onto the hospital and any further claim by the hospital would be nearly disregarded. Mistakes are made and hospitals have insurance for this reason. The difference in making a mistake and altering a record is the difference in paying a relatively small payout versus a MASSIVE fine and federal charges. Not to mention, any changes made are logged clearly within the charge, dated with a timestamp, and user logged, as well as the computer and geolocation of that user. Secondly, a baby can still be “healthy” with scleral icterus and jaundice. Many children are born with this because their liver is too premature to conjugate bilirubin and they have to be placed under a light. You are not a medical professional, so if you have questions you should ask for clarification instead of blasting it on social media. The baby likely was healthy, but to the ignorant it may seem like a false statement.
@@michaelscott33 oh my goodness a hospital doing something illegal and shady? Banish the thought! These for profit corporations that have played a vital role in muscling out physician owned hospitals are the very pinnacle and bastion of moral upstanding and legal actions.
@@michaelscott33 I'm not saying this is legal. The icterus was an example, because I couldn't remember the exact fact that they faked. Now once again: it was a birth, but the fact that they faked was about the women. Delicery went okay, baby was actually fine. But the medical docs stated that the women was fine, got up shortly after and went to the toilet to pee. While in fact she was dizzy, could not get up and also not pass urine in the bed and had to be catheterised later. Sorry for the inaccuracies, but now you have the exact facts. What do you think? Btw, this was logged in writing, no digital log. Also this did not happen in the US, but another western country.
My husband died on March 8th 2020. The hospital denied my request for records stating our 3 week old marriage license wasn't adequate proof we were married. Then they "lost" my request for 3 months. I asked the coroner's office to review my husband's chart instead of relying on the death paperwork.They had waived jurisdiction on his death and canceled his autopsy. I suspected we both had Covid-19. When I asked for a Covid-19 test for my husband the hospitalist said Covid-19 wasn't in our area yet so a test wasn't necessary. She said his imaging looked "somewhat like pneumonia". He had Covid-19 symptoms including opacities on his lungs and brain. The paperwork submitted to the coroner's office made no mention of him having a respiratory illness. Only after reviewing his records did the corner identify the images and tests done including influenza, meningitis and 2 other coronavirus strains. I learned from his records he was "rude and demanding" and while he was in respiratory distress pressing his call light for help as he died nurses were "busy with other patients". He tried to get out of his bed and got to the door. A "member of staff" told him to get back into bed before he fell down. He said "I can't breathe call 911!"collapsed and died. 6 months later the hospital sent me a letter admitting Covid-19 tests were not readily available at the time of my husband's hospitalization. 5 days after he died our state acknowledged our first positive test. Your friend is wise. No lawyers here will touch a case against this hospital. Many have worked for the hospital in litigation and claim a conflict of interest.
We had an Electronic Health Record (EHR) that was fielded to our 400+ facility organization just a couple years prior to me getting a job at one of the facilities. One day I was playing around and found that if you adjusted the date/time on your computer your note (it was in a fake training patient) reflected the date/time on your computer. I filed a work ticket as it affected enterprise wide. They didn't believe me until they looked at a couple notes (in the fake patient records) that were dated prior to WWII. It was fixed enterprise wide a few months later.
I have a rare condition with multiple co-conditions causes by it. I always request my medical records from doctors and hospitals… and wow have I seen some really un professional bs and outright lies in them.
I had two very painful mri's I got the reports. One doc did them both. One time 2:26 the other one 2:28 Corporate owned and controlled docs. Get tgebrevords, every appointment. Free here but in toledo UTMC charges 3 a page. And stretched spots to 10 pages.records a damn business.
I had this issue. Had constant pain after my first c-section, couldn’t find the cause and told to get on with it. When I had my second child, I distinctly remember the surgeon telling me not to have more children. She didn’t explain why, I was in the theatre for a long time and I was alone because my husband had left with the baby. A few weeks after, I asked for my medical records and nothing was recorded. I do not know why I should not have more children and no one can answer that question. I also have no answers to the pain I’m in. I wish the records had been more accurate.
I was at the hospital for breast care post cancer. I spoke to senior nurse, Sharon, and physio Sandra, they both introduced themselves. The records say I saw Dr Pablo Savoy. Wth?? Hospitals have to up their game, for sure.
@@warbler1984 no but it does affect follow up and also contact regarding the appointment. What if six months down the track another dr asks ‘who did you see about this?’ I have no accurate records and chemo brain, so I can’t remember. It’s not medically sound, nor scientific.
My mom died after a stint in at Atlanta hospital. She was absolutely not ready to come home but they swapped doctors that Friday morning. He walks in and she is conscious alert and sitting on the side of the bed. He's a new doctor who hadn't seen her in 4 days so he said she's doing great and discharged her. Then she crashed but the hospital still sent her home. My sister was there begging them to keep her but they literally sent her home in an ambulance. Ambulance thought she was coming home to die. She was so bad. It was Monday before we could get her back to a different hospital and then she died. It was COPD with bilateral pneumonia. Antibiotics couldn't work by that time. It wasn't until we got the actual pharmacy record that we figured out what had happened. Three different nurses had come in back to back and giving this woman an albuterol treatment and basically some speed. She was hyped up like a dime store. Junkie. No wonder she was up and around. As soon as that wore off she crashed. Should have been a lawsuit but we settled for getting a director of nursing fired.
Also sorry at the risk of sounding insensitive I am sorry to hear about what happened to your mother and that her death would have been a difficult time without any of this incompetence at such a difficult period.
For those wondering, the Electronic Medical Record (EMR) system does log every change, by time and user and you can subpoena the release of this data (this data is not in the “Normal and Customary Record” they are required to provide at your request). It is hard to understand because it is a massive data dump with numerous entries that are mundane.
I was with my wife while she was in the hospital. If you complain about another doctor, they will never make a notation of this. Even if you make a formal compliant they will feign ignorance. I take good notes and call people out even if they get angry. Everyone lies- even doctors
I've made a note of complaints about other colleagues but it's always neutral language of "patient notes does not want to be seen again by Dr Y" after all think about how Karens treat waiters...some patients treat medical staff terribly
@warbler1984 stop defending people you don't even know. There are shit nurses and doctors, just like anything else in life. As long as people act like they can do no wrong, the bad ones will never be forced to get better or leave, and eventually hospitals will become even worse than they are today.
My aunt ended up in the hospital with a nasty infection in her leg. I was present when a random doctor came by, asked about five questions, and left. We got a copy of the complete billing, and that guy added a charge of almost $1000 for "records" that were basically redundant duplicates of other work. The hospital stood by the billing as it was, of course.
Yeah, my SIL is a retired nurse and the pressure she received to "correct" records of events was incredible. Then I've been through issues where some random doctor would stop by and take a moment to check in on the patient I'm with (once was my wife, another was a friend) and we later realized said doctor was doing such a thing to justify billing the patient's medical insurance.
As a retired physician, let me weigh in with a little reality check. Medical record keeping has become almost impossible because administrators and bean counters want to cover every conceivable maloccurrence. No one ever thinks that the purpose of the record is PATIENT CARE, and that making the record harder to use, harder to extract information from, harder to navigate is making the business of patient care dangerously intricate and prone to catastrophic failure..
Yes. I worked on the exact opposite end of the spectrum (on the software itself). 99% of times when I was talking to actual end users (drs/nurses) they would ask for things that were 100% in the software but were withheld from them by admins, managers, and executives.
White out would have been even worse. It's assumed any corrections are fraudulent. Even when I was just a volunteer, I had to sit through a video saying told that white out was a banned substance and everything was in ink, not pencil. They were that serious
Subpoena the EHR or HIS system audit logs in combination with the patients chart or specific record. You will know exactly who was doing what in the system and when and begin to line up what treatments or events didn’t happen or did t happen as they described. The written document is king over their verbal.
You act like every system tracking paperwork in a hospital has audits available. That looks like that's not an experience for most of the medical professionals in these comments.
@@Greenteabook Either I am acting or I know much more about systems then you? And as someone who knows the requirement of HIPAA Security Assessments and their requirements or the facility receives lower pay from Medicare and Medicaid… yes. There are audits. You’re welcome!
@@Greenteabook The people who claim to know clearly don’t work in medical or they did forty years ago. If they do now they are the lower end of the totem pole and have no idea how the real world works. #Facts
@@Greenteabook If they're using one of the big software vendors, it's 100% being audited and its WAY more likely that the end users like Drs and nurses have no idea just how much is being tracked in the background.
I know a nurse got mad at my father in an assisted care center once and did not give him his medicine that night. That’s what he said. She said she was upset because he was mean to her, but that she did give him his medicine. I believed him even though he has some stroke related issues. The medicine reflected that the medication was given.
“The medicine reflected that the medication was not given.” What does this even mean? Also, you’re going to believe a disgruntled, post-stroke patient over the nurse? If you’re that concerned, take your father out of the assisted living.
@@michaelscott33People like you are the reason there are so many complaints about medical 'professonals'. Your reading comprehension is terrible and you assume you know what you're talking about, when you clearly misunderstood. That should be your first clue....that you are having trouble even understanding what they're talking about. That's your clue that you don't understand and need to slow down and think before speaking. Wow, just wow. You quoted them wrong and complain about not understanding what they're talking about. Yes, we can all see you don't understand...when are you going to see it???
@@sandrakeen4000 I'm a nurse who has done time in both LTC and currently work in surgical stepdown. If your dad was a stroke patient, it's very, very likely his recollection of the events of that night are inaccurate or incomplete. I'm not saying things like that don't happen, but it's very unlikely for someone to be that deliberately vindictive when the consequences could be fatal.
That's why I like being old and on social security. Because I have a hospital bill of 15000 and they processed everything except for like $800 and they sent the bill to me. I sent it back "here's the insurance company." "Well, we can't get them to pay" "well. I didn't say. I would either show me where it says. I will pay this!" They then wrote it off.😅😅😅
The Epic EMR system saved the history of notes so you can look at the original and edited notes. I found that out working at a hospital that used the system last year. I appreciated that because years ago, when the hospital I sought care from a hospital had one of the early EMR system, I was pregnant and the nurses kept deleting my vitals and updating them with a set taken later on during multiple visits so that they didn't have to record a high blood pressure. This delayed the diagnosis of PIH and preeclampsia, which could have been deadly. I was lucky I followed advice of the doctor and didn't listen to the nurse that kept claiming I was being annoying. She told me I should read a book on pregnancy instead of bothering them.
Lawyers and MBA's are part of that problem in medicine. Some hospitals (cough, Yale) associated with law schools used to infesting SCOTUS go beyond this problem, and structurally impede (a fair number of specious, as well as valid) malpractice claims. Start with a third party records contractor, so there can be finger pointing when a records request only delivers a third of the actual file or case record. Then split up nursing care, facilities, and medical services, so no one party exists with more than 50% liability when errors are made. That also works wonders in regulatory compliance to appear to have low costs, while actually having huge ones. Top that with a huge level of arrogance... There's a need for patient advocates with strong skills, but also to overhaul such systems. Ambulance chasers with unfounded malpractice claims don't help either, with the valid ones. Nor does political drug policies, that impose security threats and administrative games ahead of patient care.
TRUE.. as a nurse in the facility nor in the hospital the nurse can do all the work but if not in the "chart" it's not done and it's common in the facility's that they change all the record(re-write) everything when they get into some legal problems, and trust me in more than 20 years working in this field they will go way out to re-do all and work 24/7 to do that. they have no conscience so if you have relatives that goes in any facility "to recuperate" be vigilant because not all take their job to heart.
I was a medical transcriptionist in the 1980s and the doctors would only put in their reports what they believed was in their own best interest. The basic information about the physical attributes and age of the patients always seemed accurate; it was when the doctor described his findings and sending along a consultation with one of his buddies. Sometimes I think it’s amazing anyone has ever gotten fully appropriate treatment and hasn’t been treated for illnesses they never had.
My mom was in the ER a few months ago. I notated EVERYTHING. Everyone who talked to her and the jist of what was said, what medications they were giving her and how much, everytime her vitals changed, everything she ate, everywhere we went and which rooms we were in, and notated the times of everything. I've heard one too many horror stories and I wanted to do everything I could just in case.
I’m a lawyer who reads medical records all the time and then cross examines the doctors responsible for them, and I agree. I always find inaccuracies, sloppy mistakes, generalisations, copy and past. It horrifies me. The other problem is that doctors won’t criticise each other. Nurses have more professional independence than doctors and will happily disagree with doctor and other nurse alike. In terms of changed records , thankfully newer systems do make it impossible to change the record without the audit trail showing.
I’ve been hospitalized a few times. My immediate family members have as well. If you’re a patient, you NEED someone else there with you at the hospital if you are not as alert as you normally would be. My dad, my sister, and I have had a close call in a hospital because the staff forgot something. If someone else had not been with us at the time, we’d have been dead.
My dad was in and out of the hospital for 7 months, with 95% of that time being in the hospital and 5% of it spending no more than a week at home before having an emergency situation requiring him to go back. Problem was NEVER fixed. My dad told us about the terrible care he received from the hospital staff. So, we made sure someone was always sitting with him and taking notes of who came in, what drugs were given, what procedures, etc... The hospital did not like it. They even called security on me, told me that the staff was uncomfortable with me taking notes, and accused me of taking pictures of hospital staff when my phone was never even in my hands. I even offered for them to read my notes and go through my phone if they didn't believe me. They called security off in the end, but just goes to show you that they were nervous about me taking notes because they knew that their care was lacking. Needless to say, once we implemented this system, my dad's quality of care got much better. We honestly could have sued. Probably should. But, Dad needed a hospital and this hospital system owns most of the hospitals around and his care likely wouldn't be very good if we had an open case against them.
Dealing with this situation now. Mom fell cause a critical failure from hip replacement, she hit her head hard, showed up to ER with massive lump on back of head, they acknowledged this. Shr said her hrad and neck were in pain, they never checked it, even though we both said she has a neck cage, turns out the cage shifted in fall, one more inch and shed have been paralyzed neck down. And the doc told me directly "she's old and been through many implants, pain is normal" bro she hit her head on a full fall, onto a bathroom tub, check her neck and skull, "naw she's overreacting, we have her pain keds she'll be just fine when it's time to replace what broke in the hip"
Kind of like a member of Congress doing something illegal and then announcing he was going to form a committee to investigate himself with him in charge
My aunt was giving birth and the doctor just stopped saying "You"re not ready. Just hold on for a few hours." He went home and for the next 10 hours my aunt tried to get a nurse because she was bleeding. When one of the nurses decided to stop ignoring her she found my aunt passed out and her bed covered in blood. My aunt nearly died but thankfully her and the baby were survived. The medical records stated she refused help, the doctor was with her the whole time, and that the nurses were checking on her every hour. Medical workers are people and people will lie.
I used to work as a CNA, and I will tell you that a lot of people are really bad at what they put into the chart. If you don't write it down, it didn't happen.
What you’re talking about has nothing to do with patient care and more to do with a defense in court. A nurse may administer medication and forget to document it, it doesn’t mean it didn’t ACTUALLY happen, it means you can’t prove it for a fact without documentation. big difference.
As someone who had “record” of being given pain medication post c-section who most certainly DID NOT receive pain medication, I can attest to the fact that records can be manipulated. My postpartum nurse would enter the room while I was asleep, scan my bracelet, pocket my meds and then lie to me when I woke up screaming in pain. Worst part about it…the hospital KNEW she was doing this to people but couldn’t catch her red handed to fire her.
Doesn't it time stamp any edits? I believe Epic makes it difficult to adjust things after the fact. I can't imagine the issues with paper records! I'm doing a clinical rotation in a facility that does paper records, and I can barely read them. They have a forensics unit, so penmanship should count!
The deleted note is still in the system, just you can’t see it. The federal government has a time requirement to hold onto notes that have been submitted and/or deleted. They are all stored somewhere.
@@michaelscott33 not in my system or they dont last 8 months. When distric attorney came the note was gone. also have different requirements as its not a civilian hospital. So maybe? Not sure. The EHR is ancient
My grandma, who was a paralegal/legal secretary when she was hospitalized she wrote in a notebook every time a nurse or doctor came in, what they did, the time, medication and dose given. She was a very smart lady. Also the damn doctor kept arguing with her about her meds and telling her she needed iron because she was anemic, but she wasn’t iron deficient.
As a retired respiratory therapist, I’ve had people try to write down the names of every person that entered their room, but after a couple days, they give up, because of the sheer number of people coming in and out of patient rooms. Figure, nurses, doctors, therapists (RT, OT, PT), dietary, housekeeping, lab, X-ray, and others! Plus, if you do this, you are delaying your own care, and the care of others, as this takes time!
As someone who was in the military on subs, this is so accurate. I had to repeatedly complain to our doc to get even basic shit done, and guess what was never in my medical record, which then made fighting for VA claims that much harder. I couldn't imagine having a lawsuit with that kind of shoddy work.
We need a course of how to protect ourselves for medical negligence and malpractice. A preventative approach like this not just suffer and maybe get some money that wont nearly compensate. Malpractise is ridiculously rampant.
I went to the ER, they found out I was receiving treatment from another doctor in the system the hospital belonged to. They said there was nothing wrong, I simply had an anxiety attack. They are required to release records after 14 days, but they can release it sooner. They waited the full 14 days and the records showed my EKG had a lot of alarms on it and that there was something wrong with my heart. My trust in the system went way down after that. I was able to avoid a surgery my doctor (that I was seeing) recommended that is prepaid, and I likely wouldn’t have survived or had severe side effects from if I survived.
As a nurse I can tell you that’s 100% true. Risk management or quality will approach you and ask you to change your documentation. Most of the time you’re not lying just putting something you missed into the note. Because it documented elsewhere you did what they want you to document into the nursing or Progress notes
My wife and I had a tough delivery and I tried to write down a timeline of what was happening. At some point it drove me to exhaustion and bad to just set it aside. I don’t know how he had the discipline to constantly badger people to sign his form but i do respect Austin did this through a rough delivery - you try to do the best for your children regardless of circumstances.
My friend died on the procedure table, she was brought back on the way to the hospital. When she started looking into it, everyone was tight lipped and they could not provide any medical records…
That's smart. There is usually a whiteboard, when I dealt with my parents in the hospital I wrote on the whiteboard all activities and medicine and meals. I did this because I saw a lot of mistakes additionally we're sleep deprived so I needed to keep up with everything for myself as well and keep tabs on hospital staff.
It's not smart at all..imagine you're the on call resident and there's 90 patients under your care and you have your own documentation...you wouldn't have time for the lawyers documents...if he wants he can keep his own documentation but I won't be getting involved in it
My wife had an emergency c-section and contracted c-diff. She was sent home after 2 days even though she was anemic. We went to the same hospital 3x to tell them something wasn't right, she was extremely sick and getting worse, they just gave her an iv and sent her home. After 8 days of this,we finally saw our primary care physician and my wife was literally near death from dehydration and blood loss. After maybe 15 minutes our doctor was screaming at the head of their OB unit and my wife was in an ambulance to the ice and quarantine. She needed 2 blood transfusions, Thea member of the state medical board interviewed with us, and my wife's delivery, 2 weeks quarantine and every bill related to her pregnancy (which was not an east one obviously) disappeared (something around 400k or more I believe.) It took 3 security guards to restrain me after the doctor that did her c-section decided to make the comment of, "hey mistakes happen." Rather than apologize or admit any guilt. I wanted to burn that place to the ground.
Never trust the hospital and do your best to keep your own records, if you can. I still remember being hospitalized as a teen and my mother having to fight additional charges on our medical bill. During my stay, nurses kept adding machines to my room that I neither _needed_ nor would _ever need._ And they always did it with a smile saying they needed a place to store them. Fast forward and the hospital charged us for each piece of "stored" equipment. When we fought it, the hospital state that if it was checked into my room, used or not, then it was out of circulation and that results in a charge. It took the threat of legal action from both my mother and the insurance company to remove all those additional charges. It certainly helped that for a couple of them there were multiples of the exact same machine.
Not smart at all...when I'm on call on the Surgical ward I have 90 ward patients under my care for 10.5 hours (I've done 24 hour shifts before) I don't have time to look after them, write my own notes and then get involved in his notes which won't have any chain of custody other than himself
Just as a patient, I can tell you some stories. Like the misdiagnosed cerebral aneurysm misdiagnosed in the ER as anxiety. That ER went back and changed those records when he got wind of the accurate dx. 👍👍👍
Yes...because the healthcare staff make a decision based on your vest interest as you can't consent...if your in a coma...Will I just not give yiu the blood transfusion and let you die?
Yep. I recently received a copy of my medical records from an office where I only ever had 1 appointment. Almost the entire document was false, to the point I momentarily thought they gave me someone else's record. When I requested that they correct it, all the doctor did was add a couple notes trying, unsuccessfully, to cover their butt. The record is still wrong.
My mom did something similar. She kept a recorder on her and asked for their name and what they were doing when they came in each time plus wrote down responses to match everything. Made me do the same thing and GOD the doctors hated it. Especially when they got caught overlooking my dad being in for congestive heart failure AND kidney failure but proceeded to try to give blue dye when the previous doctor explicitly said not to. Yeah, they "slipped" in when my mom stepped out for 30 minutes. He was on dialysis shortly after they gave him blue dye despite the doctor, me, and my mother saying not to.
This happens all the time! Even in doctor's offices. I had a doctor recently commit fraud by claiming he was in the office with me for 88 minutes (and billed Medicare for 55 minutes) when he was only in the office with me for 19. In his notes, there is even a detailed physical exam that he plagiarized from some old record of mine. How do I know this? Because the entire time he was in the office with me he did not get any closer than 3 ft from my body. He never touched me and never did so much as listen to my heart (and he's a cardiologist). I reported this to the hospital's compliance office and they deemed that his billing and his records were accurate. They refused to provide me with a copy of the Epic audit log which would show what records of mine he touched. I wish Mike would take the case and sue this guy but I'm in Pennsylvania
@@Grigsy Yes it does. I am a nurse, there's 100% that feature implemented. The main problem is most EMRs have become so complex and convoluted that even superusers have a hard time recovering accurate, up-to-date information. People are so litigious now, that my job has become 50-70% CYA documentation and the remainder patient care. Of course, now that I am shackled with excessive documentation, my ability to provide patient care becomes more hindered and it turns into a vicious cycle. Combine that with understaffing and it's a wonder why MORE nurses haven't quit.
I did this exact thing when my wife went paralyzed from the waste down, when one of the hospitals refused to treat her but held her hostage for 3 days forced us to leave against medical advice, we went to another hospital and got the records transferred which said they gave her the treatment they were supposed to, but on my documentation they did not. The 2nd hospital called the first who confirmed they changed the records in an attempt to avoid a law suit
Completely correct. Specialist in a hospital entered duplicate charges on a date of service. Insurance paid the charges and kicked the dupe charges out. We were then balance billed for these duplicate charges as if they were real and not an erroneous duplicate entry. Months of back and forth before $5800 in false charges were removed. Check every line and address errors immediately. If they go to collections you have a whole new headache.
Casually changing records without patient both parties confirming and authorizing the change should come with massive fines and jail time for the administration and staff. Get it right the first time
@@Abstract_zx literally countless ways to prove that (digitally archived versions, witness confirmation, entry window deadlines etc etc) and those methods are used in literally all industries to prevent this exact issue from occuring. It is disturbing that US medicine doesn’t do this, but it’s likely something that has been lobbied for to cover the asses of doctors and hospitals.
You're allowed to edit it if it's paper...you out a line through it and initial it and write the edit time the original has to still be legible and electronic notes mark if you edit it...we are busy people and sometimes we need to edit notes in a best practice way
@@warbler1984 no one cares about excuses for laziness, incompetence or sloppiness. If it is your job or any important or official documentation, take the time and effort to get it right the first time or you deal with the consequences yourself. The entire point is that you otherwise can create problems for others that they should not have to deal with.
This will end up with "Sorry, I can't get to patient X who is dying because I'm in the middle of writing a 2 page note on patient Y and if I get it wrong I go to jail"
When I had my c-section, the nurses lied a lot. I was Pisssed! First, I found out later that they were altering how much pain I said I was in. I think to cover up for themselves because they discharged me with an active infection. I had to be rehospitalized 2 days later. Then, they give you paperwork so that your baby is known to the government and can get a birth certificate. When I tried to finish filling it out, I couldn't find it, and I asked the nurse if she took the paper to turn it in. She said, No. I didn't touch anything. I asked my family to check, and sure enough, she had. My poor kid might have had a birth certificate where their name is Baby Boy. 😁😤
Yes and no. You start doing this and having people sign in, you’re basically telling everyone that Billy badass is here to take charge and take names. People will care for you, but don’t expect anything more or anything less than what is required to get you and your baby in and out as fast as possible. We have people who log names and that is perfectly fine by me. The main reason I have had people do this is to keep track of which physician said which thing, because often times you’ll have multiple specialists on a case and you may want to ask another physician questions regarding the thing that was said. However, it hits a little different when a lawyer basically announces himself as such and demands names from the start. Before anyone replies “how would they know he’s a lawyer?!” If you don’t think nurses google this kind of stuff then you’re out of your mind. The moment he asked for the first name they will find out his name and google that immediately.
Y'all have opinions on things you don't know. "I'm an attorney" is a sure fire way to have all the staff avoid your room, and order unnecessary and dangerous test...the physicians are testing and documenting against the pending lawsuit.
When my husband was a resident an attending doctor falsified the medical records to blame a mistake during a procedure on a resident. The resident never touched the patient and luckily had a witness so he didn’t get kicked out of residency. 😏 Sometimes changes are made because the wording needs to be specific in order to bill insurance. Sometimes it’s changed because mistakes were made filling it out. Other times the hospital, provider, or nurse do it to cover their asses.
Once I stopped a nurse from giving my newborn son an injection of medication because the nurse prior said he would not be getting any at that time. So I knew.. It turns out that medication was not for him at all. She had the wrong patient. I never leave my kids or dog alone in medical care.
I had an IV put in during a hospital stay that disappeared while I was asleep. Nurse 1 said another nurse must have taken it out while I was asleep. Nurse 2 said that I pulled it out myself! Nurse 3 told me I was never given an IV at all... I was convinced I swallowed the damn IV and no one would take me seriously. Most traumatic hospital stay of my life.
My ex wife was being treated at the VA hospital. Medical records showed that she had vitals taken at various times throughout the night until morning. Except……… Her bed was against the wall. I was also in the bed. She was between me and the wall. So these multiple times they claimed to have taken vitals, they would have had to reach over me to check her, or taken my vitals instead. Neither had happened. The only accurate notation was that they found me in the morning about 15 minutes before visiting hours 🤦🏻
Walked into wife’s hospital room, late night, saw I.V. Antibiotics was not running. Called for nurse to restart. Nurse arrived with new bag, which was delivered on schedule. Threw away the almost full bag that had stopped running. Commenting “time for a new one anyway”. I’m sure records reflected she received full bag on schedule.
I'm horrified by the lack of charting. I've reviewed several appointment summaries of mine. They're so lazy. They didn't even document the reason for my visit... and nobody checks the respiratory rate. They like to say that I'm always at 18 breaths per minute, when I usually breathe between 6-8 breaths per minute. Also, when I came in complaining of tremors, the tremors were never documented even though the doctor commented on it. I'm gonna start doing this
I work in an optometry practice, and its honestly insane how easy it is for shit to be reflected wrong because of templates. If we take pictures of the back of the eye and dont need to dialate because we were able to see everything, the patients notes say they REFUSED dilation. Ive also seen notes say a patient was dispensed contacts when they never got any.
Reminded me of a story about two hospitals. It was related to infections caused by either catheters or ivs I can't remember which. Infections happen. There is only so much you can do to stop them but one hospital had less than a 1/10th of the cases of the other because their entire policy was based on that not being normal so any times there was an infection related to it they went through every single person and step related to it to find out why it became infected.
I had an emergency C-section. The ob resident didn't believe me when I told her I wasn't numb on my left side. She proceeded to make the incision as I screamed. My husband says he was led in as I passed out from pain and promptly led back out. I was put under general for the rest. I'm a physician. It happens. I knew what went wrong. I was never given an apology. I had her training credentials revoked. Had she apologized I might have backed off. Also, she documented that I was adequately numb.
My mom worked at a hospital and retired after 20 years. I have several close friends who work in the medical field. This is amazing advice, especially if you're experiencing complications.
Dude's name is 100% just "Austin" with that grin
I was thinking it must be Dallas 😂
100% Austin
@@MikeRafiLawyer Austin Powers
@@MikeRafiLawyerIt’s Justin or Mike. There is no other possibility.
I thought that he smiled because it's himself
I've investigated myself and I found myself innocent!
- hospital.
Absolutely not the case. Hospitals have oversight bodies and third parties for almost EVERY incident, even down to patient complaints. Healthcare isn’t taken lightly in the U.S.
@@michaelscott33 my grandpa died because the hospital left a pic line in him for several months. It kept growing bacteria and his body just gave out. A nurse told us about it. She wasn’t supposed to. We asked doctors involved in his healthcare about it and all we got was a “I don’t know what you’re talking” about response. Eventually one of them acknowledged it, but it never showed up in any chart or records. By the time it was taken out, his body just couldn’t fight anymore and he died days later. No lawyer would take the case because it was the hospitals word against ours.
I have no doubt that many hospitals will investigate. The problem comes with doctors who willingly lie. Falsified medical records happened with my Father-in-law and my grandpa. It didn’t kill my father-in-law, but it made his prostate cancer get treated YEARS later than it should.
well. medicine IS lawyers, the government and insurance, then the doctor, so that's why it sucks and is expensive
@@michaelscott33doctors can still decline insurance claims they don't wanna be held responsible just because they feel like it though
@@michaelscott33 That may be true to some degree, but the system fails in practice. Patients end up having to sue to get any Justice because hospitals and their staff don’t want to admit they’ve done anything wrong. What you think they’re going to have someone evaluate how badly you’ve been hurt and just give you a pot of money?
I caught a medical practice trying to bill for services they didn’t provide during a birth. Fortunately, the medical records reflected that their staff was never in the room, at any time. I was fortunate to remember, and ask the question. It was a “mistake”. Sure it was.
That does happen when staff gets sloppy and things don’t get taken out of the computer like they should so at the end of the stay when things get billed out Susie in the office doesn’t know it wasn’t done
@@JChan-ru2hfsounds plausible. Also sounds easily Exploitable by Playing dumb. And we both know someone is using that to their advantage
Where are the mistakes in the opposite direction?
Even accurate "administered $1 worth of IV fluid" and charging $100 is an additional problem.
my mom was charged this really expensive medicine four times when she only took two of the things. it was a "mistake" if my mom didn't caught it she would have paid double
My wife works at a hospital. This “Austin” guy definitely wasn’t crazy.
May you explain?
@@medoyk637look up the recent UK midazolam scandal.
@@medoyk637As someone who has had to go after hospitals over changing medical records to get away with screw ups, I sure can. I’ve had the wrong guy in detainment because the hospital lied, (medical staff tested the wrong person then lied and said they tested the right one). This has happened so many times, I now get a person tested at least at two different facilities that are unaffiliated. Wait that about sums it up, hospitals will change things or leave things out that caused harm. I’ve had some wild situations where if these people were not needed medical staff(makes them more important than a few patients), they would be in jail for the things they cover up.
@@medoyk637 overdosing the patient on certain medications and treatments for example. A chart gets mixed up so two people get the wrong thing.
For example a person I know died twice during surgery, this person was never told nor was the second time they died written down in the medical history.
They only found out after they sued the hospital for something else that happened while they were there in the hospital recovering
Thank you
Had a 6.5 minute surgery. Got billed for FOUR anesthesiologists!
Well sure. That many were required to fill out all the forms...
@agsystems8220 what's really annoying is that one of them came with their assistant to introduce themselves so I'd "know everyone who was working on me today."
Call and complain. Don't assume it's not a mistake
Anesthesia isn’t more expensive if multiple anesthesiologists signed onto your case. You may see a total for each, but it would add up to the total of only 1 anesthesiologist for 1 case.
Isn’t that odd. I just had cataract surgery with a nurse anesthetist on standby in the room just in case. But there were two claims filed. One for her and one for an anesthesiologist that was in the building but not in the OR.
That's not being paranoid, that's practicing meticulous risk management.
What is paranoia if not overly meticulous risk management?
@@888SpinR it crosses the boundary from risk management to paranoia when the risks in question become unreasonable.
@@Abstract_zxwhich is subjective
And how it is in the us (and some private hospitals here) keeping track of everything that is used or administered is also important
Which is essentially weaponized paranoia. ; )
It's like school again, when you say that you've totally done this homework and that assignment, but the teacher just forgot to write it down
Had a teacher who would collect homework in packets of 5. She lost two of my packets (two weeks worth of work) and said I didn't do them & reduced my class grade 10 points that marking period. 😡
Got a 98 (out of 99+) on my Regents (state given) test.
Which qualified me for the honors class next semester, that's a tragedy for another time. 🙃
Had college visiting teacher post final, screw with my grade claiming I didn't turn in an assignment (which would have required me to retake a class)
I produced the assignment turned in via email. Department head accused me of academic misconduct and started the process to kick me out of college and remove my progress. I challenged by contacting the Dean and the IT department. IT found the exact day and time that I had previously sent the assignment. Dean had the department put all the data back including the tampered grade. Never spoke with the Department head again.
My daughter is blind in one eye after back surgery. We know that the Drs fought over who needed to see her because we were there with her 100% of the time, it was a mess. Neurology, Opthalmology, so on. The doctors would tell us that they're trying to to get Dr so and so but he doesn't want to consult because it doesn't look like it's they're problem. Eventually the blindness in one eye reached the point where it was complete. We transfer hospitals, find out that it's not likely to come back but there's some things they can try, so we do it, and unfortunately it doesn't help. A couple months later we look into a suit, hospitals fight us and lawyer on providing records. Once we finally get them, it's the total opposite of what happened. All the specialists came and went. Performing tests and exams that they never actually did. Now lawyer tells us "but the records say they did and it's your word against theirs". So now my daughter is blind in one eye, has a back full of metal, and it just makes us cry seeing her totally transformed from a bright happy girl to being self conscious about her eye and giving up dancing that she's done all her life. All because Doctors did a shit job then lied about it.
The people are good but the system is rotten.
I wish you strength in your struggles.
@@VictoriousGardenosaurus Nah, the people aren't good. They're awful.
@@VictoriousGardenosaurusDid you read the story? Stop spreading propaganda. The workers are not good.
@@IridescentW Do you think the hospital administration changed every individual doctor record to match together? Or do you believe every doctor coordinated with each other to change the records?
I believe the former. Ipso facto, hospital administrations suck, while the doctors do not.
you could still follow with the suit, you would need a record specialist to understand the records and see if that specialist could find flaws in them. it can be easy to find if they created really fast. For example, a test is signed off by a worker but the other hospital records show that worker was not working that day. Can did this test happened when the person who signed off on it wasn't at work that day? Who did the test?
Secondly, even if others believe the records, explain why your daughter still have a black eye? what is the likely hood that the treatment that they claim they did would not work? what dod they do / talk to when they noticed that the treatment they claim they did wasn't working? Why didn't they consult an outside specialist at any point?
During the suit, you / your lawyer can ask each person who claimed to treat your daughter tons of questions. Such as, when they noticed the black eye, what days, what did they do about it, etc. all you need is for them to give contradictory statements either both the records or what the other people did. example, Dr A says he noticed it on day X but Dr B says he noticed it on day Y but day Y is before Dr A stated he told Dr B about the Eye when dr B told dr A he didn't notice it. If they knew on the same day, why are they stating the dates to be different? also if neither Day X or Y is the date listed in the file. If you noticed it on date X, why did it take to day Z to write it down?
Could still be a hard case to win depending on these factors, but it doesn't take much to show the records and statements don't add up.
Worked on medical record software. They ABSOLUTELY audit every change, who did it, and when. If they're not giving you that information, they're withholding it.
Many errors and even lies in medical records. 😮
Yeppppp.
INTRODUCING: Paper Notes! Shitty hopsitals hold onto them for obvious reasons!
AND they're incentivized to withhold/change it... you can't trust their records for shit.
They can't be honest about the cost of service, why the hell would they care about being honest about what they did?
So true. My father-in-law’s dad died of prostate cancer and when my father-in-law had elevated PSA numbers, his doctor blew him off for years as the number climbed. My mother-in-law blew her top and insisted on getting test and seeing a specialist.
FIL ended up having cancer. The medical records sent to the cancer center indicated that my MIL had brushed off the doctor and his concern for the numbers and refused any further investigation. According to the records, it was the doctor that stood up to my MIL and insisted on testing. Apparently my father-in-law was just a bystander.
Medical professionals will lie to get out of trouble and have no problem falsifying records.
I have actually witnessed forgery of physician signatures. I have seen dates on medical records where neither the physician nor the patient were even in the hospital.
I remember when I had oral surgery when I was 10 they couldn't find the problem that was on the X-rays, when my grandfather went to the dentist to get the original X-rays to give to the oral surgeon the dentist magically lost all the files.
My grandfather had all his children change dentists that day
If your granddad was like my aunt and uncle, who had 14 kids, that dentist lost a lot of money.
@@jdstep97 big time
Sounds like he was scamming to get more money
I was in the hospital for 2 nights a while back. I got into the room around 3pm, so I asked my wife to bring me my cpap device and mask, which I need to sleep. When I got the bill for the stay, there was an $800x2 charge for CPAP / breathing therapy. NOBODY ever talked to me about the cpap or did any breathing therapy. When I challenged it, the hospital said that they had provided the service. I asked for names of the therapists, test results and my cpap device settings…. Then asked again… then asked again. He fourth time I asked, they graciously comped me the $1600.
Dad had an employee that ended up in a medically induced coma for months. (Nearly fatal infection raging throughout his body.) His wife took time off of her job to essentially live in the hospital with him to guard him. She learned the SOP for his care and also learned about all of the different medicines that may be used. Some medications could not be used together. Some medications were ones that he himself could not have. She developed a curiosity, and then a routine, of always tracking what was being given to her husband. Most of the staff admired that he had such a strong advocate and didn't mind. Unfortunately, not all of the staff. One of the staff didn't check in with her, and instead just walked up to the patient to immediately add a syringe to the IV bag. On principle, the wife was upset; but she also felt strong internal alarm bells go off. She hollered out to stop. She tried to overcome her anger and adrenaline. She tried to stay polite. She had noticed that the person had not double checked the chart before administering a drug. She asked what it was. Again, the wife had to consciously overcome an instinctive desire to scream and attack. Instead, she told the person to wait and pushed the button for more help. The wife didn't trust herself around this person. Had that drug been administered, our friend would have been dead in minutes. It's been decades since this event. Specific details are no longer in my memory. But I can still viscerally remember how his wife was crashing off adrenaline and rage, and how panicked that ICU staff was after the fact. It cemented for me how important it is to have a main advocate; and to even create a schedule of friends, family, teammates, coworkers, etc to rotate a bedside vigil so that patients don't have to be alone. Hospital staff, no matter how professional they are, get busy and make mistakes, and/or forget that they can't take out a stressful day on the patient in the bed.
This could not happen without serious negligence or malice. There are protocols in place to prevent administration of a medication not belonging to the patient. Meds have to be removed from a central dispenser called an Omnicell for each patient. Before the order from the prescriber is approved and the medication available to be dispensed from the Omnicell, the pharmacist must verify it. Then the med is programmed into the Omnicell for that specific patient. The nurse then checks for any contraindications and removes it from the Omnicell. Then the patient must be scanned, the med must be scanned and the order accepted in the computer at bedside. At this point, the medication has been verified, the patient has been verified and the nurse can then administer the medication. Additionally, medications aren't added to a bag at bedside - ever. If a med is to be given by IV, the fluids are paused, the IV detached, the line is flushed, the med given per protocol outlined above, then the line is flushed again before reattaching the fluids and restarting the pump.
@@CraftHarlot Did it ever occur to you that statistics of cases like our friend is *WHY* all of the safeguards are in place now? BTW, don't be cocky about that list of safeguards. People are still given the wrong medications.
It's still a major cause of loss of life(medical malpractice) oopps?
@elizabethbottroff1218
@@CraftHarlot- and yet it happens.
@@CraftHarlot the person said this happened decades ago. Omnicell, scanning bracelets, etc. wouldn't have been a thing then. I had my oldest child 18 years ago and there were just handwritten paper bracelets inside plastic.
A friend's baby died during birth. The midwife failed to detect fetal heartbeat several times, but didn't call an ambulance until it was too late. She later falsified the records, showing her recording the heart beat while the call logs showed she was talking to a consultant at the time.
Having a baby at home was that friend’s first mistake.
People don’t like your comment, but It needs to be higher.
Ask any paramedic or EMT what they fear, and it is childbirth.
Sure, if everything goes perfect it is going to be fine. But the risks for women are not low. They are high. Modern medicine has made child birth extremely safe.
But modern medicine means being in a hospital.
Not your house.
Fortunately I live in a country where people give birth in hospitals, with a doctor in the room, because we are not mentally stuck in the 18th century and we know giving birth at home or under a tree is a stupid idea. And that's why our infant mortality is less than half compared the USA. In other words, baby born in the USA is more than twice as likely to die in childbirth. than here.
It was already safer to give birth here than in the USA 20 years ago, when we were still a developing country.
Did they go to court? If the call logs prove the false medical records, surely they have a case?
@@neverstopschweiking Even just having midwives for at home births better regulated makes it a safer situation. At home births are riskier in the US because there are people practicing as midwives when they are not qualified and get away with it until tragedy happens (at least we hope they don't get away with it).
So true! For my Sister’s birth, the Obstetrician didn’t show for the entire birth and when my mother stood up to go get him because my father was grabbing a nurse, my sister came out… my father managed to get back in time to grab my sister before she hit the floor while the nurse had to grab my mother. She (mother) ended up with 3rd degree tears amongst other things from the birth. Apparently, the hospital just so happened to “lose” her medical records just after the surgery for her injuries… -_-
Edit:
1. They went private for the doctor, so she paid this guy $5000 for him to no-show, 3. She also lost 1/3rd of her bowel. The main reason for the damage was that they didn’t turn the head during the birth so the shoulders “ripped her to shreads” (quote by mum), 4. Furthermore, 5 days after the birth, right before discharge, they asked if she had passed a motion (the answer was no). They ended up giving her charcoal, then a pill to get her to, which led to convulsions down there… As you could imagine, giving the damage and the amount of stitches she had, it was VERY painful. 5. This was in Aus
What actual fuck!!!!!😲😲😲😲
Where was this, Mexico? You do understand that “losing” medical records is more of a problem for the hospital than anything you wrote in your story here, which I do find hard to believe. Furthermore, per hospital policy your mother would have been at fault if the baby had hit the floor. Women who are about to give birth are ordered strict bed rest unless supervised. I find this story very difficult to believe on its merit alone.
-infectious disease and critical care physician.
@@michaelscott33the fuck you got mexico from?
@@michaelscott33why do you assume it was in Mexico?
@michaelscott33 that bed rest is probably the reason she had more tears, cause giving birth on your back is harder and leads to lots more tearing.
Considering the pride of medical staff I've worked with, how did he get the nurses and MDs to fill out the forms?
Those of us take pride in our work jump at the chance. We are often doing what other should’ve done and taking up the slack. It’s frustrating when others don’t do their job and any chance to correct this is great.
@@jessicarogers9420wrong form of proud
@@jessicarogers9420 that’s not the type of pride they were talking about.
Either because they're ethical or the combination of fear and peer pressure
@@jessicarogers9420Medical industry pawns working overtime to try and save face in the comments.
So true, I have false medical record of my surgery. I complained to my surgeon who agrees with me, but the hospital refuses to change it.
You've left out all the rest if the story??
@@warbler1984- is it any of your business?
Threaten to sue. If it’s easier to fix it than spend 30k in court fees to start a battle , they often just fix it- but be pushy.
I worked in hospitals for over 30 years, starting as a clerk and ending as a health professional. When I started all charts were paper. Charting had to be physically continuous on the paper, I.e., nurse signs off from day shift, overnight nurse signs on on the next line. It would have been almost impossible for someone to change a note after the fact as there physically wasn't any space you could use. If a nurse made an error, she would have to cross out the error, write ERROR above it, initial and date it, and show it to the charge nurse. It was obvious. But with electronic records, as a patient you're at the mercy of the programmers, who I'm certain were never drilled on the sanctity, if you will, of medical records. If the software doesn't keep an audit record, you're out of luck, my friend. And the people overseeing the acquisition of the electronic chart system, wouldn't know what an audit trail was if it reared up and bit them.
…I was building a scheduling system, for hair cuts and spas and training and whatever, _and I baked record-keeping into the damn thing!_
Maybe 20 yrs ago when my drs were just getting into digital records, I was sent a link to mine that was actually for another patient with a name not at all similar to mine. Oops. Didn’t look at them but did call the records center to tell them, they were surprised, worried, thanked me profusely, and got on it right away.
I don’t trust digital records but have resigned myself to the inevitability of them.
This is a dumb take
"Paper is immune to fraud" is what you're trying to say
I respect your distrust of computers but, you don't have a point here
@@SicFromTheKushreading comprehension clearly isn’t your strong suite. Paper can be harder to fraudulently change, because at the very least, an audit system EXISTED. Coders, on the other hand, might not have understood the importance of tracking minute changes, hence, programs MIGHT NOT EVEN HAVE ANY audit system.
@@SicFromTheKush”almost impossible to change” is a pretty big difference than “immune to fraud”
I worked in med rec 15yrs. I wish everyone took it as serious as I did cause they are not always complete or accurate. Then some docs refuse to do addendum once an issue is brought up. Some thanked me for catching issues though. I felt bad for patients who relied on these recs.
Huh? I’m a physician and have no idea what you’re talking about. Med Rec is when we take the patient’s home medications and reconcile them with what we have in their medical chart to ensure they’re getting accurate medications. There is no place to make an “addendum” even if a correction is needed. The med rec is SUPPOSED to be completed by the nurse and pharmacist, but I always end up doing it because the system fails the patient and the nurses are so ego-driven it’s beyond them to take a second to reconcile the meds. However, when they actually do reconcile them in the computer, it’s typically just them pressing “submit” and not even checking if they’re correct. It sickens me and pisses me off. I was a nurse for 10 years prior to becoming a physician and I’m starting to really have hatred for my old profession.
@@michaelscott33Rec = records 🙄🙄🙄 That was obvious.
When i had baby #5 she was taken to the NICU following nurses observing what they believed to be seizure activity. Seizure activity in a newborn is a very big deal. I was recovering from a C-section and, thank God, had my husband to assist me going to the NICU to spend time with my newborn. Overnight and for one day my husband was unable to be present and during that time a nurse of mine decided she was going to manipulate the way she followed doctors orders because she personally believed i should be taking narcotic pain killers for at least three days following my C-section. I had already discussed with my doctor, and explained to her, that i wanted to be off any narcotic or opioid medications as soon as possible, that i had done well in the past with a Tylenol-Ibuprofen rotation with the medications taken simultaneously, then gradually spacing out.
I was on narcotic pain medication for either 2 or 3 days, I'm still not sure which, and had a lot of trouble knowing how much time was passing. I was supposed to be caring for my newborn during this time, and with her in the NICU I needed to be pumping every two hours to establish milk supply. The narcotics stunted my milk coming in for days.
Luckily my milk came in, i was okay, baby was okay, and my night nurse realized what happened, advocated for me, and raised hell behind the scenes. But this person is absolutely not crazy
"Pumping" is NOT the same as pure breastfeeding. There are hormones involved from both mother & baby which are necessary to establish & maintain b/feeding.
When my daughter was born, I basically wrote a book the first night in the hospital to journal that day and what the experience was like because I wanted to remember what labor was like when our kids are grown.
And when I say I wrote a book, I mean, it’s a How I Met Your Mother level of detail. I documented every single conversation down to the word, every single thing I experienced down to the texture of the hospital chair, and every single thing I saw and heard down to cars I passed on the road. I literally wrote down everything I could remember.
And after seeing this, I’m willing to bet my notes were probably more accurate than the nurses there considering they do that job every day and I was shooting for accuracy for the sake of my own memory. I kind of had more at stake because having your first child is a once in a lifetime experience, and I wanted more than anything to remember everything.
I would bet it was as or more accurate than what the nurses wrote...they have to look after multiple patients and then document while you sit in a chair and document
Also the nurse, housekeeper, doc and any staff that walked in could care less about 99% of what you wrote. They are only concerned about their task and what they are going to cook for dinner. Most of our tasks are auto tracked with a official timestamp.
It's really cool that you did that.
Also hospitals cover their tracks very well when something goes wrong
MyChart keeps **amazing** audit trails. Don't let anybody tell you otherwise.
That's so true. When medical records are requested (here usually by an insurance), the hospital will go over them with a lawyer and make sure everything is correct.
A friend had a case where she requested the record just for her own interest (legal right here), and the requested record was in great detail. But some things were blatantly wrong. Something along the lines of "baby healthy" and some more descriptions. And actually the baby had some issues, icterus or similar and had been treated.
Clearly a faked record and some data added with a different pen. Ridiculous.
I am a physician and medical admin -
What you are claiming here is blatantly false and ABSOLUTELY illegal beyond belief. You are talking about a hospital committing federal crimes. No one would dare change the medical record, because the moment a change is made after the fact it draws suspicion onto the hospital and any further claim by the hospital would be nearly disregarded. Mistakes are made and hospitals have insurance for this reason. The difference in making a mistake and altering a record is the difference in paying a relatively small payout versus a MASSIVE fine and federal charges. Not to mention, any changes made are logged clearly within the charge, dated with a timestamp, and user logged, as well as the computer and geolocation of that user.
Secondly, a baby can still be “healthy” with scleral icterus and jaundice. Many children are born with this because their liver is too premature to conjugate bilirubin and they have to be placed under a light. You are not a medical professional, so if you have questions you should ask for clarification instead of blasting it on social media. The baby likely was healthy, but to the ignorant it may seem like a false statement.
@@michaelscott33 oh my goodness a hospital doing something illegal and shady? Banish the thought! These for profit corporations that have played a vital role in muscling out physician owned hospitals are the very pinnacle and bastion of moral upstanding and legal actions.
@@michaelscott33No one would ever do something illegal🙄
@@michaelscott33my boyfriend is a physician and has witnessed this at multiple hospitals
@@michaelscott33 I'm not saying this is legal.
The icterus was an example, because I couldn't remember the exact fact that they faked.
Now once again: it was a birth, but the fact that they faked was about the women.
Delicery went okay, baby was actually fine. But the medical docs stated that the women was fine, got up shortly after and went to the toilet to pee.
While in fact she was dizzy, could not get up and also not pass urine in the bed and had to be catheterised later.
Sorry for the inaccuracies, but now you have the exact facts.
What do you think? Btw, this was logged in writing, no digital log.
Also this did not happen in the US, but another western country.
My husband died on March 8th 2020. The hospital denied my request for records stating our 3 week old marriage license wasn't adequate proof we were married. Then they "lost" my request for 3 months. I asked the coroner's office to review my husband's chart instead of relying on the death paperwork.They had waived jurisdiction on his death and canceled his autopsy. I suspected we both had Covid-19. When I asked for a Covid-19 test for my husband the hospitalist said Covid-19 wasn't in our area yet so a test wasn't necessary. She said his imaging looked "somewhat like pneumonia". He had Covid-19 symptoms including opacities on his lungs and brain. The paperwork submitted to the coroner's office made no mention of him having a respiratory illness. Only after reviewing his records did the corner identify the images and tests done including influenza, meningitis and 2 other coronavirus strains. I learned from his records he was "rude and demanding" and while he was in respiratory distress pressing his call light for help as he died nurses were "busy with other patients". He tried to get out of his bed and got to the door. A "member of staff" told him to get back into bed before he fell down. He said "I can't breathe call 911!"collapsed and died. 6 months later the hospital sent me a letter admitting Covid-19 tests were not readily available at the time of my husband's hospitalization. 5 days after he died our state acknowledged our first positive test. Your friend is wise. No lawyers here will touch a case against this hospital. Many have worked for the hospital in litigation and claim a conflict of interest.
I'm sorry you've had to go through this. 😢
We had an Electronic Health Record (EHR) that was fielded to our 400+ facility organization just a couple years prior to me getting a job at one of the facilities.
One day I was playing around and found that if you adjusted the date/time on your computer your note (it was in a fake training patient) reflected the date/time on your computer.
I filed a work ticket as it affected enterprise wide.
They didn't believe me until they looked at a couple notes (in the fake patient records) that were dated prior to WWII.
It was fixed enterprise wide a few months later.
My doctor billed my insurance for delivery when, in fact, he never showed up. I was told not to push until I couldn't not anymore.
I have a rare condition with multiple co-conditions causes by it. I always request my medical records from doctors and hospitals… and wow have I seen some really un professional bs and outright lies in them.
I had two very painful mri's I got the reports. One doc did them both. One time 2:26 the other one 2:28
Corporate owned and controlled docs. Get tgebrevords, every appointment. Free here but in toledo UTMC charges 3 a page. And stretched spots to 10 pages.records a damn business.
I had this issue. Had constant pain after my first c-section, couldn’t find the cause and told to get on with it. When I had my second child, I distinctly remember the surgeon telling me not to have more children. She didn’t explain why, I was in the theatre for a long time and I was alone because my husband had left with the baby. A few weeks after, I asked for my medical records and nothing was recorded. I do not know why I should not have more children and no one can answer that question. I also have no answers to the pain I’m in. I wish the records had been more accurate.
I was at the hospital for breast care post cancer. I spoke to senior nurse, Sharon, and physio Sandra, they both introduced themselves. The records say I saw Dr Pablo Savoy. Wth?? Hospitals have to up their game, for sure.
Did that affect your care in a material way?
@@warbler1984 no but it does affect follow up and also contact regarding the appointment. What if six months down the track another dr asks ‘who did you see about this?’ I have no accurate records and chemo brain, so I can’t remember. It’s not medically sound, nor scientific.
My mom died after a stint in at Atlanta hospital. She was absolutely not ready to come home but they swapped doctors that Friday morning. He walks in and she is conscious alert and sitting on the side of the bed. He's a new doctor who hadn't seen her in 4 days so he said she's doing great and discharged her. Then she crashed but the hospital still sent her home. My sister was there begging them to keep her but they literally sent her home in an ambulance. Ambulance thought she was coming home to die. She was so bad. It was Monday before we could get her back to a different hospital and then she died. It was COPD with bilateral pneumonia. Antibiotics couldn't work by that time.
It wasn't until we got the actual pharmacy record that we figured out what had happened. Three different nurses had come in back to back and giving this woman an albuterol treatment and basically some speed. She was hyped up like a dime store. Junkie. No wonder she was up and around. As soon as that wore off she crashed. Should have been a lawsuit but we settled for getting a director of nursing fired.
Also sorry at the risk of sounding insensitive I am sorry to hear about what happened to your mother and that her death would have been a difficult time without any of this incompetence at such a difficult period.
Settled for a firing? Rather than get 2 mil...
@@machinmon.Money is all they know. U want change you hsve to hit them in the pocketbook.BTW. seems like you fired the wrong person.
Sounds like they got away with it tbh
@@machinmon. WE'd been through hell at that point and were just over it.
For those wondering, the Electronic Medical Record (EMR) system does log every change, by time and user and you can subpoena the release of this data (this data is not in the “Normal and Customary Record” they are required to provide at your request). It is hard to understand because it is a massive data dump with numerous entries that are mundane.
I was with my wife while she was in the hospital. If you complain about another doctor, they will never make a notation of this. Even if you make a formal compliant they will feign ignorance. I take good notes and call people out even if they get angry. Everyone lies- even doctors
House: Everyone lies
I've made a note of complaints about other colleagues but it's always neutral language of "patient notes does not want to be seen again by Dr Y" after all think about how Karens treat waiters...some patients treat medical staff terribly
@warbler1984 stop defending people you don't even know. There are shit nurses and doctors, just like anything else in life. As long as people act like they can do no wrong, the bad ones will never be forced to get better or leave, and eventually hospitals will become even worse than they are today.
I work in a hospital, there are many things that happen to a patient that the staff are instructed to not put in the record.
My aunt ended up in the hospital with a nasty infection in her leg. I was present when a random doctor came by, asked about five questions, and left. We got a copy of the complete billing, and that guy added a charge of almost $1000 for "records" that were basically redundant duplicates of other work. The hospital stood by the billing as it was, of course.
If anyone besides a lawyer tried that in a hospital delivery room they'd be escorted out with cuffs on.
Yeah, my SIL is a retired nurse and the pressure she received to "correct" records of events was incredible. Then I've been through issues where some random doctor would stop by and take a moment to check in on the patient I'm with (once was my wife, another was a friend) and we later realized said doctor was doing such a thing to justify billing the patient's medical insurance.
As a retired physician, let me weigh in with a little reality check. Medical record keeping has become almost impossible because administrators and bean counters want to cover every conceivable maloccurrence. No one ever thinks that the purpose of the record is PATIENT CARE, and that making the record harder to use, harder to extract information from, harder to navigate is making the business of patient care dangerously intricate and prone to catastrophic failure..
Yes. I worked on the exact opposite end of the spectrum (on the software itself). 99% of times when I was talking to actual end users (drs/nurses) they would ask for things that were 100% in the software but were withheld from them by admins, managers, and executives.
I'm not in health care, but have heard about these problems and wondered this.
Long time ago, back before computers, I worked for an OB/GYN. I remember a rushed demand for White Out and a particular patient's operative report...
Right…
White out would have been even worse. It's assumed any corrections are fraudulent.
Even when I was just a volunteer, I had to sit through a video saying told that white out was a banned substance and everything was in ink, not pencil. They were that serious
It was illegal to use white out on medical records. You had to put only one line through the part you wanted to change and initial, date and time it.
Subpoena the EHR or HIS system audit logs in combination with the patients chart or specific record. You will know exactly who was doing what in the system and when and begin to line up what treatments or events didn’t happen or did t happen as they described. The written document is king over their verbal.
You act like every system tracking paperwork in a hospital has audits available. That looks like that's not an experience for most of the medical professionals in these comments.
@@Greenteabook Either I am acting or I know much more about systems then you? And as someone who knows the requirement of HIPAA Security Assessments and their requirements or the facility receives lower pay from Medicare and Medicaid… yes. There are audits.
You’re welcome!
@@Greenteabook The people who claim to know clearly don’t work in medical or they did forty years ago. If they do now they are the lower end of the totem pole and have no idea how the real world works.
#Facts
@@Greenteabook If they're using one of the big software vendors, it's 100% being audited and its WAY more likely that the end users like Drs and nurses have no idea just how much is being tracked in the background.
I know a nurse got mad at my father in an assisted care center once and did not give him his medicine that night. That’s what he said. She said she was upset because he was mean to her, but that she did give him his medicine. I believed him even though he has some stroke related issues. The medicine reflected that the medication was given.
“The medicine reflected that the medication was not given.” What does this even mean?
Also, you’re going to believe a disgruntled, post-stroke patient over the nurse? If you’re that concerned, take your father out of the assisted living.
@@michaelscott33 it was a long time ago. He passed away 20 years ago.
@@michaelscott33you respond to every message
We get it you’re salty that people are not satisfied with the healthcare system
@@michaelscott33People like you are the reason there are so many complaints about medical 'professonals'. Your reading comprehension is terrible and you assume you know what you're talking about, when you clearly misunderstood. That should be your first clue....that you are having trouble even understanding what they're talking about. That's your clue that you don't understand and need to slow down and think before speaking. Wow, just wow. You quoted them wrong and complain about not understanding what they're talking about. Yes, we can all see you don't understand...when are you going to see it???
@@sandrakeen4000 I'm a nurse who has done time in both LTC and currently work in surgical stepdown.
If your dad was a stroke patient, it's very, very likely his recollection of the events of that night are inaccurate or incomplete.
I'm not saying things like that don't happen, but it's very unlikely for someone to be that deliberately vindictive when the consequences could be fatal.
That's why I like being old and on social security. Because I have a hospital bill of 15000 and they processed everything except for like $800 and they sent the bill to me.
I sent it back "here's the insurance company."
"Well, we can't get them to pay"
"well. I didn't say. I would either show me where it says. I will pay this!"
They then wrote it off.😅😅😅
The Epic EMR system saved the history of notes so you can look at the original and edited notes. I found that out working at a hospital that used the system last year. I appreciated that because years ago, when the hospital I sought care from a hospital had one of the early EMR system, I was pregnant and the nurses kept deleting my vitals and updating them with a set taken later on during multiple visits so that they didn't have to record a high blood pressure. This delayed the diagnosis of PIH and preeclampsia, which could have been deadly. I was lucky I followed advice of the doctor and didn't listen to the nurse that kept claiming I was being annoying. She told me I should read a book on pregnancy instead of bothering them.
My wife almost had emergency c-section 8 weeks early because a nurse recorded some bleeding as 900 cc loss. When it was really only 9 cc...
Lawyers and MBA's are part of that problem in medicine.
Some hospitals (cough, Yale) associated with law schools used to infesting SCOTUS go beyond this problem, and structurally impede (a fair number of specious, as well as valid) malpractice claims.
Start with a third party records contractor, so there can be finger pointing when a records request only delivers a third of the actual file or case record.
Then split up nursing care, facilities, and medical services, so no one party exists with more than 50% liability when errors are made. That also works wonders in regulatory compliance to appear to have low costs, while actually having huge ones.
Top that with a huge level of arrogance...
There's a need for patient advocates with strong skills, but also to overhaul such systems. Ambulance chasers with unfounded malpractice claims don't help either, with the valid ones. Nor does political drug policies, that impose security threats and administrative games ahead of patient care.
TRUE.. as a nurse in the facility nor in the hospital the nurse can do all the work but if not in the "chart" it's not done and it's common in the facility's that they change all the record(re-write) everything when they get into some legal problems, and trust me in more than 20 years working in this field they will go way out to re-do all and work 24/7 to do that.
they have no conscience so if you have relatives that goes in any facility "to recuperate" be vigilant because not all take their job to heart.
I was a medical transcriptionist in the 1980s and the doctors would only put in their reports what they believed was in their own best interest.
The basic information about the physical attributes and age of the patients always seemed accurate; it was when the doctor described his findings and sending along a consultation with one of his buddies.
Sometimes I think it’s amazing anyone has ever gotten fully appropriate treatment and hasn’t been treated for illnesses they never had.
My sister is looking for a malpractice lawyer, it’s apparent that the hospital messed up and it resulted in her newborn passing away. Pennsylvania
My mom was in the ER a few months ago. I notated EVERYTHING. Everyone who talked to her and the jist of what was said, what medications they were giving her and how much, everytime her vitals changed, everything she ate, everywhere we went and which rooms we were in, and notated the times of everything. I've heard one too many horror stories and I wanted to do everything I could just in case.
This reminds me of the movie The Verdict. The doctors change a medical record to hide their mistake.
I’m a lawyer who reads medical records all the time and then cross examines the doctors responsible for them, and I agree. I always find inaccuracies, sloppy mistakes, generalisations, copy and past. It horrifies me. The other problem is that doctors won’t criticise each other. Nurses have more professional independence than doctors and will happily disagree with doctor and other nurse alike. In terms of changed records , thankfully newer systems do make it impossible to change the record without the audit trail showing.
"Let's call him Austin. When Austin had his baby, it wasn't easy ."
I can't imagine a man having a baby that WAS an easy delivery!!
I’ve been hospitalized a few times. My immediate family members have as well. If you’re a patient, you NEED someone else there with you at the hospital if you are not as alert as you normally would be. My dad, my sister, and I have had a close call in a hospital because the staff forgot something. If someone else had not been with us at the time, we’d have been dead.
Mike makes me think of Wesley from The Rookie and I can’t unsee it😂😂
yes!!!
My dad was in and out of the hospital for 7 months, with 95% of that time being in the hospital and 5% of it spending no more than a week at home before having an emergency situation requiring him to go back. Problem was NEVER fixed.
My dad told us about the terrible care he received from the hospital staff. So, we made sure someone was always sitting with him and taking notes of who came in, what drugs were given, what procedures, etc... The hospital did not like it. They even called security on me, told me that the staff was uncomfortable with me taking notes, and accused me of taking pictures of hospital staff when my phone was never even in my hands. I even offered for them to read my notes and go through my phone if they didn't believe me. They called security off in the end, but just goes to show you that they were nervous about me taking notes because they knew that their care was lacking. Needless to say, once we implemented this system, my dad's quality of care got much better. We honestly could have sued. Probably should. But, Dad needed a hospital and this hospital system owns most of the hospitals around and his care likely wouldn't be very good if we had an open case against them.
It's hard to imagine any hospital staff putting up with that. 🤨
Dealing with this situation now. Mom fell cause a critical failure from hip replacement, she hit her head hard, showed up to ER with massive lump on back of head, they acknowledged this. Shr said her hrad and neck were in pain, they never checked it, even though we both said she has a neck cage, turns out the cage shifted in fall, one more inch and shed have been paralyzed neck down. And the doc told me directly "she's old and been through many implants, pain is normal" bro she hit her head on a full fall, onto a bathroom tub, check her neck and skull, "naw she's overreacting, we have her pain keds she'll be just fine when it's time to replace what broke in the hip"
Kind of like a member of Congress doing something illegal and then announcing he was going to form a committee to investigate himself with him in charge
My aunt was giving birth and the doctor just stopped saying "You"re not ready. Just hold on for a few hours." He went home and for the next 10 hours my aunt tried to get a nurse because she was bleeding. When one of the nurses decided to stop ignoring her she found my aunt passed out and her bed covered in blood. My aunt nearly died but thankfully her and the baby were survived. The medical records stated she refused help, the doctor was with her the whole time, and that the nurses were checking on her every hour. Medical workers are people and people will lie.
I used to work as a CNA, and I will tell you that a lot of people are really bad at what they put into the chart. If you don't write it down, it didn't happen.
What you’re talking about has nothing to do with patient care and more to do with a defense in court. A nurse may administer medication and forget to document it, it doesn’t mean it didn’t ACTUALLY happen, it means you can’t prove it for a fact without documentation. big difference.
As someone who had “record” of being given pain medication post c-section who most certainly DID NOT receive pain medication, I can attest to the fact that records can be manipulated. My postpartum nurse would enter the room while I was asleep, scan my bracelet, pocket my meds and then lie to me when I woke up screaming in pain. Worst part about it…the hospital KNEW she was doing this to people but couldn’t catch her red handed to fire her.
Doesn't it time stamp any edits? I believe Epic makes it difficult to adjust things after the fact. I can't imagine the issues with paper records! I'm doing a clinical rotation in a facility that does paper records, and I can barely read them. They have a forensics unit, so penmanship should count!
It does. Epic is probably the best. The one I use though you can delete whole notes. The system will show a delete but not what you orginal charted.
The deleted note is still in the system, just you can’t see it. The federal government has a time requirement to hold onto notes that have been submitted and/or deleted. They are all stored somewhere.
@@michaelscott33 not in my system or they dont last 8 months. When distric attorney came the note was gone. also have different requirements as its not a civilian hospital.
So maybe? Not sure. The EHR is ancient
@@pfc_church if it's Epic, the hospital 100% has the data.
My grandma, who was a paralegal/legal secretary when she was hospitalized she wrote in a notebook every time a nurse or doctor came in, what they did, the time, medication and dose given. She was a very smart lady. Also the damn doctor kept arguing with her about her meds and telling her she needed iron because she was anemic, but she wasn’t iron deficient.
As a retired respiratory therapist, I’ve had people try to write down the names of every person that entered their room, but after a couple days, they give up, because of the sheer number of people coming in and out of patient rooms. Figure, nurses, doctors, therapists (RT, OT, PT), dietary, housekeeping, lab, X-ray, and others! Plus, if you do this, you are delaying your own care, and the care of others, as this takes time!
As someone who was in the military on subs, this is so accurate. I had to repeatedly complain to our doc to get even basic shit done, and guess what was never in my medical record, which then made fighting for VA claims that much harder. I couldn't imagine having a lawsuit with that kind of shoddy work.
We need a course of how to protect ourselves for medical negligence and malpractice. A preventative approach like this not just suffer and maybe get some money that wont nearly compensate. Malpractise is ridiculously rampant.
I went to the ER, they found out I was receiving treatment from another doctor in the system the hospital belonged to. They said there was nothing wrong, I simply had an anxiety attack. They are required to release records after 14 days, but they can release it sooner. They waited the full 14 days and the records showed my EKG had a lot of alarms on it and that there was something wrong with my heart. My trust in the system went way down after that. I was able to avoid a surgery my doctor (that I was seeing) recommended that is prepaid, and I likely wouldn’t have survived or had severe side effects from if I survived.
People need to be shamed out of the profession for this evil deeds.
People get killed for lesser faults.
As a nurse I can tell you that’s 100% true. Risk management or quality will approach you and ask you to change your documentation. Most of the time you’re not lying just putting something you missed into the note. Because it documented elsewhere you did what they want you to document into the nursing or
Progress notes
My wife and I had a tough delivery and I tried to write down a timeline of what was happening. At some point it drove me to exhaustion and bad to just set it aside.
I don’t know how he had the discipline to constantly badger people to sign his form but i do respect Austin did this through a rough delivery - you try to do the best for your children regardless of circumstances.
My friend died on the procedure table, she was brought back on the way to the hospital. When she started looking into it, everyone was tight lipped and they could not provide any medical records…
That's smart. There is usually a whiteboard, when I dealt with my parents in the hospital I wrote on the whiteboard all activities and medicine and meals. I did this because I saw a lot of mistakes additionally we're sleep deprived so I needed to keep up with everything for myself as well and keep tabs on hospital staff.
It's not smart at all..imagine you're the on call resident and there's 90 patients under your care and you have your own documentation...you wouldn't have time for the lawyers documents...if he wants he can keep his own documentation but I won't be getting involved in it
My wife had an emergency c-section and contracted c-diff. She was sent home after 2 days even though she was anemic. We went to the same hospital 3x to tell them something wasn't right, she was extremely sick and getting worse, they just gave her an iv and sent her home. After 8 days of this,we finally saw our primary care physician and my wife was literally near death from dehydration and blood loss. After maybe 15 minutes our doctor was screaming at the head of their OB unit and my wife was in an ambulance to the ice and quarantine. She needed 2 blood transfusions, Thea member of the state medical board interviewed with us, and my wife's delivery, 2 weeks quarantine and every bill related to her pregnancy (which was not an east one obviously) disappeared (something around 400k or more I believe.) It took 3 security guards to restrain me after the doctor that did her c-section decided to make the comment of, "hey mistakes happen." Rather than apologize or admit any guilt. I wanted to burn that place to the ground.
Austin watching this:
👀
👄
Never trust the hospital and do your best to keep your own records, if you can.
I still remember being hospitalized as a teen and my mother having to fight additional charges on our medical bill. During my stay, nurses kept adding machines to my room that I neither _needed_ nor would _ever need._ And they always did it with a smile saying they needed a place to store them.
Fast forward and the hospital charged us for each piece of "stored" equipment. When we fought it, the hospital state that if it was checked into my room, used or not, then it was out of circulation and that results in a charge. It took the threat of legal action from both my mother and the insurance company to remove all those additional charges. It certainly helped that for a couple of them there were multiples of the exact same machine.
That's a very smart thing to do. Especially these days. I hope more people start doing this. Thanks.
Not smart at all...when I'm on call on the Surgical ward I have 90 ward patients under my care for 10.5 hours (I've done 24 hour shifts before) I don't have time to look after them, write my own notes and then get involved in his notes which won't have any chain of custody other than himself
Just as a patient, I can tell you some stories. Like the misdiagnosed cerebral aneurysm misdiagnosed in the ER as anxiety. That ER went back and changed those records when he got wind of the accurate dx. 👍👍👍
For sure. Sometimes, people get treatment that they consented to when they were unconscious
Yes...because the healthcare staff make a decision based on your vest interest as you can't consent...if your in a coma...Will I just not give yiu the blood transfusion and let you die?
Yep. I recently received a copy of my medical records from an office where I only ever had 1 appointment. Almost the entire document was false, to the point I momentarily thought they gave me someone else's record. When I requested that they correct it, all the doctor did was add a couple notes trying, unsuccessfully, to cover their butt. The record is still wrong.
Report them for lying
As a fellow Austin I concur
My mom did something similar. She kept a recorder on her and asked for their name and what they were doing when they came in each time plus wrote down responses to match everything.
Made me do the same thing and GOD the doctors hated it. Especially when they got caught overlooking my dad being in for congestive heart failure AND kidney failure but proceeded to try to give blue dye when the previous doctor explicitly said not to.
Yeah, they "slipped" in when my mom stepped out for 30 minutes. He was on dialysis shortly after they gave him blue dye despite the doctor, me, and my mother saying not to.
As someone who works in the OR: Austin is not crazy.
This happens all the time! Even in doctor's offices. I had a doctor recently commit fraud by claiming he was in the office with me for 88 minutes (and billed Medicare for 55 minutes) when he was only in the office with me for 19. In his notes, there is even a detailed physical exam that he plagiarized from some old record of mine. How do I know this? Because the entire time he was in the office with me he did not get any closer than 3 ft from my body. He never touched me and never did so much as listen to my heart (and he's a cardiologist). I reported this to the hospital's compliance office and they deemed that his billing and his records were accurate. They refused to provide me with a copy of the Epic audit log which would show what records of mine he touched. I wish Mike would take the case and sue this guy but I'm in Pennsylvania
The fact that Epic doesn't Version Control doctor /nurse notes is insane.
It 100% does at every location it's used. I worked on it.
@@Grigsy Yes it does. I am a nurse, there's 100% that feature implemented.
The main problem is most EMRs have become so complex and convoluted that even superusers have a hard time recovering accurate, up-to-date information.
People are so litigious now, that my job has become 50-70% CYA documentation and the remainder patient care. Of course, now that I am shackled with excessive documentation, my ability to provide patient care becomes more hindered and it turns into a vicious cycle. Combine that with understaffing and it's a wonder why MORE nurses haven't quit.
I did this exact thing when my wife went paralyzed from the waste down, when one of the hospitals refused to treat her but held her hostage for 3 days forced us to leave against medical advice, we went to another hospital and got the records transferred which said they gave her the treatment they were supposed to, but on my documentation they did not. The 2nd hospital called the first who confirmed they changed the records in an attempt to avoid a law suit
Honestly. Smart af once u explained it
Completely correct. Specialist in a hospital entered duplicate charges on a date of service. Insurance paid the charges and kicked the dupe charges out. We were then balance billed for these duplicate charges as if they were real and not an erroneous duplicate entry. Months of back and forth before $5800 in false charges were removed.
Check every line and address errors immediately. If they go to collections you have a whole new headache.
Casually changing records without patient both parties confirming and authorizing the change should come with massive fines and jail time for the administration and staff. Get it right the first time
how would you prove that they changed or didnt change it
@@Abstract_zx literally countless ways to prove that (digitally archived versions, witness confirmation, entry window deadlines etc etc) and those methods are used in literally all industries to prevent this exact issue from occuring. It is disturbing that US medicine doesn’t do this, but it’s likely something that has been lobbied for to cover the asses of doctors and hospitals.
You're allowed to edit it if it's paper...you out a line through it and initial it and write the edit time the original has to still be legible and electronic notes mark if you edit it...we are busy people and sometimes we need to edit notes in a best practice way
@@warbler1984 no one cares about excuses for laziness, incompetence or sloppiness. If it is your job or any important or official documentation, take the time and effort to get it right the first time or you deal with the consequences yourself. The entire point is that you otherwise can create problems for others that they should not have to deal with.
This will end up with "Sorry, I can't get to patient X who is dying because I'm in the middle of writing a 2 page note on patient Y and if I get it wrong I go to jail"
When I had my c-section, the nurses lied a lot. I was Pisssed!
First, I found out later that they were altering how much pain I said I was in.
I think to cover up for themselves because they discharged me with an active infection. I had to be rehospitalized 2 days later.
Then, they give you paperwork so that your baby is known to the government and can get a birth certificate. When I tried to finish filling it out, I couldn't find it, and I asked the nurse if she took the paper to turn it in. She said, No. I didn't touch anything.
I asked my family to check, and sure enough, she had. My poor kid might have had a birth certificate where their name is Baby Boy. 😁😤
"Let me tell you how to receive poor care at a hospital in 30 seconds." 😂
Then the lawyer will have an accurate recording of this
Yes and no.
You start doing this and having people sign in, you’re basically telling everyone that Billy badass is here to take charge and take names. People will care for you, but don’t expect anything more or anything less than what is required to get you and your baby in and out as fast as possible.
We have people who log names and that is perfectly fine by me. The main reason I have had people do this is to keep track of which physician said which thing, because often times you’ll have multiple specialists on a case and you may want to ask another physician questions regarding the thing that was said. However, it hits a little different when a lawyer basically announces himself as such and demands names from the start. Before anyone replies “how would they know he’s a lawyer?!” If you don’t think nurses google this kind of stuff then you’re out of your mind. The moment he asked for the first name they will find out his name and google that immediately.
Y'all have opinions on things you don't know. "I'm an attorney" is a sure fire way to have all the staff avoid your room, and order unnecessary and dangerous test...the physicians are testing and documenting against the pending lawsuit.
Ur 100% correct!!! O was a nurse for a long time, saw charts changed many times to protect the staff/Doctor/Hospital. Many times!!!
When my husband was a resident an attending doctor falsified the medical records to blame a mistake during a procedure on a resident. The resident never touched the patient and luckily had a witness so he didn’t get kicked out of residency. 😏 Sometimes changes are made because the wording needs to be specific in order to bill insurance. Sometimes it’s changed because mistakes were made filling it out. Other times the hospital, provider, or nurse do it to cover their asses.
Once I stopped a nurse from giving my newborn son an injection of medication because the nurse prior said he would not be getting any at that time. So I knew.. It turns out that medication was not for him at all. She had the wrong patient. I never leave my kids or dog alone in medical care.
I had an IV put in during a hospital stay that disappeared while I was asleep. Nurse 1 said another nurse must have taken it out while I was asleep. Nurse 2 said that I pulled it out myself! Nurse 3 told me I was never given an IV at all... I was convinced I swallowed the damn IV and no one would take me seriously. Most traumatic hospital stay of my life.
My ex wife was being treated at the VA hospital.
Medical records showed that she had vitals taken at various times throughout the night until morning.
Except………
Her bed was against the wall.
I was also in the bed.
She was between me and the wall.
So these multiple times they claimed to have taken vitals, they would have had to reach over me to check her, or taken my vitals instead.
Neither had happened.
The only accurate notation was that they found me in the morning about 15 minutes before visiting hours 🤦🏻
Walked into wife’s hospital room, late night, saw I.V. Antibiotics was not running. Called for nurse to restart. Nurse arrived with new bag, which was delivered on schedule. Threw away the almost full bag that had stopped running. Commenting “time for a new one anyway”. I’m sure records reflected she received full bag on schedule.
I'm horrified by the lack of charting. I've reviewed several appointment summaries of mine. They're so lazy. They didn't even document the reason for my visit... and nobody checks the respiratory rate. They like to say that I'm always at 18 breaths per minute, when I usually breathe between 6-8 breaths per minute. Also, when I came in complaining of tremors, the tremors were never documented even though the doctor commented on it. I'm gonna start doing this
I work in an optometry practice, and its honestly insane how easy it is for shit to be reflected wrong because of templates. If we take pictures of the back of the eye and dont need to dialate because we were able to see everything, the patients notes say they REFUSED dilation. Ive also seen notes say a patient was dispensed contacts when they never got any.
Reminded me of a story about two hospitals. It was related to infections caused by either catheters or ivs I can't remember which. Infections happen. There is only so much you can do to stop them but one hospital had less than a 1/10th of the cases of the other because their entire policy was based on that not being normal so any times there was an infection related to it they went through every single person and step related to it to find out why it became infected.
I had an emergency C-section. The ob resident didn't believe me when I told her I wasn't numb on my left side. She proceeded to make the incision as I screamed. My husband says he was led in as I passed out from pain and promptly led back out. I was put under general for the rest.
I'm a physician. It happens. I knew what went wrong. I was never given an apology. I had her training credentials revoked. Had she apologized I might have backed off.
Also, she documented that I was adequately numb.
My mom worked at a hospital and retired after 20 years. I have several close friends who work in the medical field.
This is amazing advice, especially if you're experiencing complications.