Medical Records

"The breasts are symmetrical in size, shape and architecture."

Well, who knew? I shared this little tidbit with Katz this morning over breakfast, quoting information my doctor had noted in my medical records during an annual breast exam 10 years back.

The notes from a routine physical were also interesting: "The patient denies skin rashes or itching. Denies slurred speech, double vision, imbalance or headache. Denies feeling blue, depressive symptoms, sleep loss or psychiatric hospitalization." There are also denials about my GI tract, joints, eyes, mouth and heart. After reading this summation, I felt more like I'd been through a criminal investigation than through a check up. Oh, I know questions were asked and answered, it all just felt more conversational and less like a cross examination than the records indicate.

I also found records of a pelvic ultrasound I never had revealing cysts I never had. My records indicate the procedure was conducted on the same day I had a mammogram. My name is on the results of both procedures, but the date of birth is wrong for the ultrasound.

All in all, between interesting word choices and the inclusion of someone else's information, it was an interesting read. It was made all the more interesting because my medical records were almost lost forever.

With the advent of electronic records, more and more paper records are being destroyed daily. A trip to a new ENT who wanted more information on my thyroid cancer from 10 years ago revealed that my old records were missing. With no pathology report or surgeon's notes and recommendations to support my assertion that surgery removed the cancer and resulted in a complete cure, this new doctor suggested I have a MRI.

I balked. I've decided recently it's important in these times of rampant medical tests and out of control costs to challenge physicians on why a test is being ordered, how necessary it is, and what are the physical and financial ramifications of having the test done. Turns out, she told me, if she had my records, she wouldn't need the MRI.

So, four weeks and multiple phone calls later and after some interference from Katz (who happens to work for my health care provider), my records were found. After insisting that pertinent information regarding my cancer history be entered into my electronic record, Katz and I both got our own copies of our records.

So, moral of the story: Don't let flattery distract you (Symmetrical shape and architecture? You sweet talker, you!). Call your doctor and find out how far back your medical history goes and if it doesn't go back far enough, make some noise.