Daily Archives: March 14, 2006

On the accuracy of medical records

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Last year, I went to the emergency room at the same time as someone else: Both of us were asthmatic and both had been exposed to some sort of really nasty toxin that was a byproduct of the construction process in our building. (Right after we had been assured by the housing authority that everything was safe in here. I have never had breathing problems as bad as that, or anything that felt even remotely like that, even when I inhaled smoke once in a kitchen fire.)

Anyway, we eventually got our medical records from that visit, to show the housing authority so they would relocate us somewhere breathable.

It was very interesting. My records claimed that I had a history of severe scoliosis and allergies to medications that I am not allergic to. I think her records noted allergies to medications that I am allergic to, as well as other elements of my medical history. In other words, despite the fact that they seemed to question us each separately and enter us into the computer separately, they got all the data jumbled. That is scary.

Scarier is that I’ve seen other of my medical records. They often mess up things as routine as what city I live in. Sometimes they confuse me with other patients. Sometimes they add fictional bits of medical history that never existed, sometimes they leave out things that did exist.

Some are undoubtedly deliberately fudged.

I have on tape a description by a tester of fudging an IQ test so my weak points would not show up, which has me even more convinced that IQ testing is not as “objective” as people claim it is.

On a more sinister note, I have the records of the time I experienced attempted murder by neglect, and things were clearly charted in such a way as to make even the medications I was given at the time look much different, more according to procedure, more innocuous than they were. (When they did not succeed in allowing me to die the first time I had an obvious dangerous reaction to a drug, they gave it to me a second time “just to make sure” and told me that they would give me an antidote if I would agree to do what they told me in other areas. Records of that time document a slow increase in that medication (never happened) until an adverse reaction happened and it was discontinued (not quite).)

I’ve seen instances in which what they told me was not what they wrote down. When we had the breathing problems, they talked all about how they could hear the big difference in lung volume after breathing treatment, and exactly what was going on and stuff, but when they wrote it up they wouldn’t mention things like this, although they would sometimes exaggerate what we said about what we were planning to do about all this. In that case, since it was tied to a somewhat high-profile controversy in the area, I suspect they were covering their asses (one doctor even explained to us that he couldn’t write something a certain way because although he believed it was that way, he was afraid if it showed up in court he wouldn’t be able to prove it 100%, because there is no way of proving that particular symptom 100%), but it doesn’t make it right.

I have also had people invent elements of my life that don’t exist, as if out of thin air.

I once had a case manager write in my file that I was working for my landlord in exchange for rent. I never did anything like that so I don’t know where she came up with it. She also fabricated diagnoses out of thin air, and claimed I’d told them to her, when I’d never heard of them before. On the other hand, the diagnoses she was faxed by my doctor, for physical problems, were disregarded in favor of her imaginary diagnoses and of psychological problems. The most bizarre part was that she said all of this, and all her other distortions of my life, were what I had told her. I had told her nothing of the sort. She didn’t like me, though, and I think that was a lot of what happened. She told me not to be so confrontational before I’d had a chance to type a single word to her. She seemed to not be responding to reality much at all.

But others just seem accidentally, but dangerously, careless.

Switching around elements of my medical history and the history of the woman who came to the emergency room with me is bizarre and dangerous but probably not deliberate.

A lot of the factual errors are probably similar. Stuff that people got confused.

But what disturbs me is that medical records like this are taken as more factual than anything else. Clearly, from my experience and others, they can be either deliberately fudged or unintentionally screwed up in other ways. Yet medical records are supposed to be some kind of reality. They are sometimes treated as more real than real. This is strange.