Fact Versus Fiction in Medical Records

As a lot of you know, I have been dealing with a foot wound that keeps getting progressively worse. The most frustrating part of this for me is dealing with doctors and trying to get medical records straightened out. I have started to write a couple times about the things that have happened since I last wrote on March 5th – every time I start to write, I start to cry. I am going to save that stuff for another day!

I sent for my last set of records from the Ohio Valley General Hospital Wound Care Center. Even though they are the ones that changed my appointment in December, they closed my file and started me as a new patient, yet again. The envelope came the other day and I was afraid to open it. I opened it this morning and let’s just say, there is a reason some of us should not own guns! I am apparently “problematic” because I chose to get the mistakes from the October records corrected. I have a five page letter with corrections this time but thought I would share one big thing here.

When I was at the wound center on February 7th, the doctor gave me a script to get a PICC line inserted and start on Vancomycin. With Vancomycin, they measure the levels in your blood weekly and adjust it up or down depending on the levels in your blood.

This was in my records for February 28th:

Ohio Valley General Hospital Wound Care Center, Dr. Peter Dickinson notes for Kelly Booth

This was the actual script that I was given on February 7th:

Ohio Valley General Hospital prescription written by Dr. Peter Dickinson for Kelly Booth

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Foot: Rollercoaster to Insane Nightmare

I looked at my blog this AM and just saw it has been a month since I last posted.  After my last post, I saw the doctor at Pittsburgh wound center.  I told him that I wanted to try antibiotics and not surgery. 

They made arrangements for me to get a PICC line in, which I did on Monday, February 11th.   Protocols have changed since I was last on IV antibiotics and you now have to have your first infusion done at a hospital and not at home.  I had my first bag of Vancomycin done at the hospital that day.  It was a very long day and I was exhausted when I got home.  The next morning, the home nurse came in to get me started on doing it myself at home.

Friday morning, she had to come back to do blood work.  With Vancomycin, they need to test your levels to make sure you are getting enough of it in your blood.  I didn’t have enough so they upped my dose for Saturday morning.

The following Tuesday, I woke up really sick in my stomach, had a headache and the start of a rash on my face.  I very rarely get headaches so that was not normal for me.  I had a rash from Vancomycin before but it wasn’t on my face.  Nausea, headaches and rashes are all side effects of Vancomycin. 

The nurse was coming again for more blood work.  Later that afternoon, the pharmacist at the infusion company called to tell me that my levels were still low and they needed to up my dose again.  I told her about being sick and was concerned that it was from the increased Vancomycin levels.  She told me that they would only send a small amount of the Vancomycin and would check on me on Wednesday.

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Foot Rollercoaster: Osteomyelitis, Idiots and Hard Decisions

As some of you know, I have been dealing with what started as a minor foot ulcer last April. I started having problems with an infection last fall and it seems like it has been downhill ever since. When I was on antibiotics, I felt better and my foot felt better. I would finish the antibiotics, get sick again and my foot was really sore. I heard from several doctors that I did not have an infection – they made that decision on how my foot looked, not on any blood tests to check for infection. One doctor did order a bone scan in November and that came back that I had a soft tissue infection. He still insisted I did not have an infection and I was not placed on antibiotics.

I was in the hospital before Christmas and that was a nightmare! After I came home, I went to a walk-in clinic and the nurse practitioner there did blood work and placed me on an antibiotic. She also wanted to follow me until my appointment at the wound center.

I had an appointment scheduled for Friday, December 28th at the wound center. About 3:00 PM the afternoon before, they called me to reschedule that appointment. I ended up having to wait 3 weeks to get in. When I tried to tell her that I was sick, the nurse blew off my having an infection because the culture came back negative when I was in the hospital. When I tried to tell her that they kept putting me back on the same antibiotic and it didn’t seem to be killing whatever it was I had, she told me which antibiotic I was on didn’t matter. Anyone that has ever seen a culture knows that statement is just not true!

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Hospital Nightmare and Escape!

I ended up in the hospital with an infected foot. Last Friday, I went to get some NPH insulin because I still didn’t have good Levemir. Novo Nordisk replaced the 2nd bad box with the same lot number and that was also bad. They wouldn’t ship it Friday because my area doesn’t have Saturday FedEx deliveries – it was going to be Tuesday until I could get it.

I don’t know if it was the NPH or something else, but I gained 3 pounds between Saturday and Sunday and another 5 pounds between Sunday and Monday – and no, I wasn’t snacking on Christmas cookies! I was really swollen and when I took the bandage off my foot Monday morning, my foot was getting red. I “thought” it was because my bandage being tight when my foot swelled up. I didn’t think it was infected because my blood sugar was doing really good (other than the bad Levemir and testing out NPH). I didn’t feel good but I thought that was from being exhausted – that was day 8 of taking insulin every 2 hours and I was really to drop over.

Tuesday morning when I went to get my shower, I took the dressing off and the red had spread so I knew it was infected. I called my mother to come and take me to the ER. We went to the local ER at Conemaugh Hospital. The doctor agreed it was most likely infected so he did some blood work. My SED rate and white blood cell count were both up and he wanted to admit me. I didn’t want to be admitted there because I go to the wound center at Ohio Valley General Hospital in Pittsburgh and since it was a wound related problem, wanted to go there. They were great in calling Pittsburgh to get me transferred there.

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More Lying Doctors and I Am Fuming!

The manager knocked on my door with a big envelope – they put some of my mail in her box. My records finally came from the doctor that I had to file a complaint with both the attorney general’s office and the PA licensing board in order to get them. I scanned in the page for my last visit with him and put it at the bottom of this post – that is what has me fuming!

I first looked to make sure the x-rays were in there. When I switched to this doctor, the doctor that did the x-rays would not give them directly to me to take but wanted to forward them himself. My first appointment, they looked at them and the doctor told the nurse to keep them. In my letter requesting my records, I asked him to forward the x-rays back to the original doctor if he could not send them to me. He sent them to me, but they were in the original envelope the other doctor used, along with a note that they were originals and should be returned within 2 weeks. This is 3 ½ years later and I now have them. That tells you right there the character of this doctor.

Of course according to him, I did NOT listen and had I listened, my foot would have healed months before. I expected him to put that in there. For several months before my deciding to change doctors, my sister who is a nurse kept telling me that what the doctor was doing was causing my foot to get worse – now she is enjoying saying I told you so. I did everything he told me to do and that did make my foot worse. He had me putting moleskin around the wound and that pulled the skin off – everything I have read says not to put sticking things on compromised skin because it makes it worse. I can attest to that one! He also had me leaving the bandages on way too long and having a moist wound bed promotes healing.

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Some Good, Some Bad and Letter to Doctor

I am participating in Wego Health’s National Health Blog Post Month. I am not using the prompts again today. Today is the last day! Not sure how I mad it with all the crap stuff going on, but somehow I made it.

I have an appointment to go back to the wound center in Pittsburgh. I wasn’t sure if I had burned my bridges there by sending the letter with all the mistakes in my records. I called the person at the hospital that I had talked to and referred to TuDiabetes. I won’t quote her response, but she was glad that I wanted to come back. She told me that I made her day so that certainly made me feel good. The errors weren’t medical errors, they were errors in my records but the electronic records concern me that someone will see those and they spread.

Doctors carrying computerShe told me that they were finished with the corrections but one doctor forgot to sign his so she had sent it back to get his signature on. She said both doctors agreed with everything I stated except the one that called me old. He would not change one thing. My gut tells me that it is the old comment but I will wait to see the report. They had on there that I was allergic to Xanax and I never used that drug. Apparently, he dictated latex but the transcriptionist heard Latex. I haven’t looked too deep into the correction process yet to know if I am allowed to “disagree” with his refusal to correct something.

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