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?
On our old emar system, we could only remove medications from someone's med list if we were the one that prescribed them. So daily, when reviewing meds, we'd say "and are you still taking XYZ?" And they'd say no, but since WE weren't the prescribing provider, we weren't able to remove them. Now that we have a new EHR, any provider can update med lists in instances like this.
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.
definitely shouldn't have been in the current diagnoses for that visit but honestly if you were there in the past for those reasons the previous visits never go away and all staff have access to your chart history and would see it anyway. I dont see the difference.
In my experience, it is mostly medical assistants, not nurse, who help with the physician or NP in urgent care. I know that there are places where there are nurses but mostly, it's just me and the physician in the back. We aren't allowed to remove those diagnosis or change them from active to inactive. I would highly suggest speaking with your PCP or the urgent care physician if the UC isn't attached to your doctor's office and ask that it be removed from the active problem list. Same with medications: at my old healthcare system, only the doctor could remove the medication, not the MA.
At my current health care system, I am allowed to remove meds only with notes that state that it is per patient request. The urgent care may not have known or had updates since those issues were discussed. Yes we read the discharge papers, but that is to help you if the doctor wrote any specific instructions or if he/she sent the rx to the correct pharmacy and try to help you as much as we can.
BuckyBadgerRN, ASN, RN
3,520 Posts
On our old emar system, we could only remove medications from someone's med list if we were the one that prescribed them. So daily, when reviewing meds, we'd say "and are you still taking XYZ?" And they'd say no, but since WE weren't the prescribing provider, we weren't able to remove them. Now that we have a new EHR, any provider can update med lists in instances like this.