Am I right to be angry?

[Knytstar]

I recently went to an urgent care clinic run by one of the major health care corporations in my area. I was seeking tx for a minor eye injury (corneal abrasion). Everyone from the receptionist, nurses, and doctor were friendly and attentive. It was a fairly painless visit in regards to crowded waiting room, wait time to be seen, etc. The care I received was stellar. From my registration paperwork the staff knew that I am also a nurse; so there was a little shop talk about where I work. You know, just friendly conversation between the clinic nurses and myself while my discharge forms were being printed out. While reviewing post care instructions and prescriptions, my nurse briefly got a confused look on his face. Just a fleeting moment. I thought nothing of it at the time. Later, when I got home to review my papers, my heart sank. Already teary-eyed from the corneal abrasions I felt fresh tears welling up. On the last page of discharge instructions was a section addressing current conditions and reasons for visit. 1. Alcohol withdrawal. 2. Suicidal Precautions. 3. Corneal Abrasions. Now mind you, this standardized form from the major health care system included old patient information from over 14 years ago. Yes I received tx way back when for problems that seemed like a lifetime ago. I have come so far since then and rarely even think about those unhappy times. I remembered the look my nurse gave me and realized why. I almost feel that this health care company breached confidentiality. Those nurses didn't need to know about my past to care for me that night. Why did that information print out? I don't understand. I am not ashamed, just felt like a punch in the gut seeing it listed as a current condition. I tried to contact their (company, not clinic) medical records department to at least change things to "history of...", but no luck so far. I'm not sure how to pursue correcting this. Any advice?

[sallyrnrrt, ADN, RN]

Rather bizarre, discharge instructions and reason for visit should have paralleled your presenting symptomology,

assessment,

and treatment given,

land follow up instructions

[EDRNCCmom, MSN, RN]

Rather bizarre, discharge instructions and reason for visit should have paralleled your presenting symptomology,

assessment,

and treatment given,

land follow up instructions

I agree with this train of thought. In the ED I work in, discharge instructions are catered towards diagnosis. If you come in for abdominal pain which turns out benign, you get a basic handout on abdominal pain.

I have noticed that my family doctors discharge paperwork always list all my diagnosis. Even the acne which I had as a teenager but no longer have. I always smirk when I see the list of things that I no longer have. Maybe they can bill more if more diagnosis are listed!??

[Susie2310]

If I had a PCP with the organization I received care from I might start there, or if I could access my health information online I would see if I could request that the changes are made. It sounds to me as though your information may just need to be updated in their records. Did you ask the medical records department how to request that these changes are made?

[nutella, MSN, RN]

I assume it is a larger system with a EHR? There is a designated person who deals with patient concerns and complains regarding the information in the EHR. If they have a patient portal you can sign up and see what else information is there and it often also includes a link or name to email with concerns about the information in the EHR.

It is possible that those problems from back then are still listed as "active problems" and will continue to come up.

The EHR is good in many regards but sometimes it can turn into a curse. I stayed with a PCP who still operated with paper because I am somewhat paranoid about all the info that can accumulate in a EHR. When I changed providers, I was careful which information I supplied.

You know all those form in which they ask for history of and such - I almost never fill in anything that is not super relevant.

[bugya90, ASN, BSN, LVN, RN]

In our EHR if no one ever removed those from the "active problem" list instructions print out every time for it. Which is great for HTN and DM, not so much for the the things above.

[Kitiger, RN]

Don't be angry; just fix their problem. I would start with the patient portal.

[AutumnApple]

Hmph, I think you fell victim to a phenomenon that I've talked about before.

We don't know the variables and details of everything that goes on around us. We just see the end result. Then, we assume everyone else is judging the situation by our criteria and take it personally when their actions/decisions seem to (by our criteria) say something about us.

You see, nursing preaches against being task oriented, yet often at the same time promotes it. And so too does everyone else. We're so busy with our daily lives, our 'tasks' at work and everything else, we often treat sensitive things as though they are just another task to be done with and rid of.

We check the box we feel is appropriate (by our criteria) or is safest for us, and move on.

Not much time for taking into consideration how checking that box on the task list affects others. Welcome to the information era where lives are changed with the click of a button. It's as if our keyboard/mouse has turned into a gun, and we pull the trigger so recklessly.

Lots of people clicking this/that and the other box lead to that information being on your discharge papers. And at this point, I am positive you've put more thought into it than any other player in this story has. It was just a task to them, another box to check.

It could be the nurse who gave you said discharge papers was performing the nursing process. He saw a well adjusted, stable person. Then he read the information. It confused him because the information didn't match what he had assessed. His mind ran through a bunch of things for a few moments: 'Could this have been a self inflicted injury?' and all sorts of things. He decided, correctly, that information no longer applied and continued on with his discharge duties as he saw fit.

My advice, laugh it off (easier said than done), follow up and find out why it was there then correct it. Undo all the 'task oriented' button clicking that lead to it being there.

[RiskManager]

Noting that the OP is in Washington state, state law provides an explicit method of asking for the record to be corrected or amended at RCW 70.02.100. What I would do is to communicate with the Medical Records office of the healthcare system via email; tell them that you are making a request to have the record amended pursuant to RCW 70.02.100 and specify exactly what you want them to do. This will trigger the amendment/correction process at the system, and they have to give you a response within a specific time frame. Note that the system need not comply with your request, but if they do not, they must give you the opportunity to file a statement of disagreement as per RCW 70.02.110.

Having said all of this, this comes up in our EHR, and it goes away if it is removed from the active problem list. Usually.

[h=4]RCW 70.02.100[/h]

[h=4]Correction or amendment of record.[/h]

(1) For purposes of accuracy or completeness, a patient may request in writing that a health care provider correct or amend its record of the patient's health care information to which a patient has access under RCW 70.02.080.

(2) As promptly as required under the circumstances, but no later than ten days after receiving a request from a patient to correct or amend its record of the patient's health care information, the health care provider shall:

(a) Make the requested correction or amendment and inform the patient of the action;

(b) Inform the patient if the record no longer exists or cannot be found;

© If the health care provider does not maintain the record, inform the patient and provide the patient with the name and address, if known, of the person who maintains the record;

(d) If the record is in use or unusual circumstances have delayed the handling of the correction or amendment request, inform the patient and specify in writing, the earliest date, not later than twenty-one days after receiving the request, when the correction or amendment will be made or when the request will otherwise be disposed of; or

(e) Inform the patient in writing of the provider's refusal to correct or amend the record as requested and the patient's right to add a statement of disagreement.

[ClaraRedheart, BSN, RN]

I'm so sorry. I've gone through things before that I am SO grateful have never been on a medical record (though, I'm sure they could have been had anyone forced me to go to the hospital). I don't even like THINKING about it. I can't imagine if that were on a medical record that was thrown in my face with every visit. I agree with what the others have said. Do what you can to have it changed. But yes, you have every right to be upset.

[norlns24]

The OP's post is sobering. In two separate health systems, I am asked about medications (for pain) I was prescribed ONE TIME and never ended up even taking (rx'd for pain related to surgery complications that thankfully subsided and is no longer an issue). In both health systems, these medications are listed as active and I am asked about them religiously at each visit. I have repeatedly told the nurses reviewing my history who have asked about these medications to change my health record to indicate I am not actively taking these medications and NO LUCK! I was seen just a few weeks ago for a regular ENT appt. and was asked yet again about past medications I have never even taken and that were prescribed only one time! This situation imo is potentially counter-productive.

I get the rationale for electronic medical records. I get the rationale for continuity of care. However, patients deserve some control over their own medical record and records need to better reflect current health states. In my med surg clinical, we read a very powerful editorial from a journalist with a bipolar disorder dx who has been treated differently and unjustly refused medication by her PCP for pain based on this stigmatizing MH dx. This situation is more than a bit out of control. Yes, OP, you have a right to be hurt and even angry about your discharge instructions. No one should be judged for or permanently labeled by their darkest day.

[BuckyBadgerRN, ASN, RN]

Yup. As long as it's listed on active problems, it will attach itself to EVERY visit. At least that is how our system works.

I'm really confused by "the look on the face" of the discharging nurse. THAT part seems the most unprofessional to me.

In our EHR if no one ever removed those from the "active problem" list instructions print out every time for it. Which is great for HTN and DM, not so much for the the things above.