missing information odd??

[taddles]

What is the name of your state (only U.S. law)? PA
i had requested my complete medical chart from a surgery i had at a major hospital. I typed out exactly what i wanted to be included rather then let there be a miscommunication. i asked for nurse, RESIDENT, surgeon, CT scans, labs, medication log and all progress notes relating to hospital stay.

they failed to send any resident notes. i saw a resident every day for 12 days. sometimes a different one on the same day.
my question is, does a red flag go off the minute a patient requests a compete chart like that? obviously they are guessing i want it for a very good reason. and beings i paid very good money for that chart, isn't it odd that every resident note was excluded?? so now if i request the missing informaiton, it will cost more for those pages rather then if i paid for them in the first request. the bottom pages even stated ____ page of 265. i certainly did not get that many pages.
is it common practice to omit information like that then to wait and see if it is re-requested or i just go away??

 

[lealea1005]

What is the name of your state (only U.S. law)? PA
i had requested my complete medical chart from a surgery i had at a major hospital. I typed out exactly what i wanted to be included rather then let there be a miscommunication. i asked for nurse, RESIDENT, surgeon, CT scans, labs, medication log and all progress notes relating to hospital stay.

they failed to send any resident notes. i saw a resident every day for 12 days. sometimes a different one on the same day.
my question is, does a red flag go off the minute a patient requests a compete chart like that? obviously they are guessing i want it for a very good reason. and beings i paid very good money for that chart, isn't it odd that every resident note was excluded?? so now if i request the missing informaiton, it will cost more for those pages rather then if i paid for them in the first request. the bottom pages even stated ____ page of 265. i certainly did not get that many pages.
is it common practice to omit information like that then to wait and see if it is re-requested or i just go away??

Since they are Physicians, the resident's notes are not normally seperated specifically as, say, Nursing notes. Also, there may be pages that are intentially left blank for whatever reason, or not applicable to be included in copies of a record. Fax cover pages, for example.

 

[taddles]

okay so i get the fact that the number of pages may not be a perfect match, however i am not sure i understand why a resident does not have a resposnibility to record in a patient chart. i had an open wound and a resident came in each morning to unpack, stick her fingers in my abdominal cavity, repack and state it's progress. why not necessary to write in chart?? i had my surgical incision opened after surgery based on another residents supposed findings. i was specifically told by the surgeon "the resident said...." but it si not documented anywhere. no need to document?? seems a little sketchy to me. it is not like the doctor had notes in the chart for each day representing the resident...so basically it is as if i never saw these residents?????

 

[lealea1005]

okay so i get the fact that the number of pages may not be a perfect match, however i am not sure i understand why a resident does not have a resposnibility to record in a patient chart. i had an open wound and a resident came in each morning to unpack, stick her fingers in my abdominal cavity, repack and state it's progress. why not necessary to write in chart?? i had my surgical incision opened after surgery based on another residents supposed findings. i was specifically told by the surgeon "the resident said...." but it si not documented anywhere. no need to document?? seems a little sketchy to me. it is not like the doctor had notes in the chart for each day representing the resident...so basically it is as if i never saw these residents?????

Where did I say anything about the Resident Physician's responsibility to chart??? I said a Resident IS a Physician and, his/her charting would be included as part of the Physician notes/charting/recording.

 

[taddles]

okay so let me rephrase....is it odd that there are not daily physician dictation whether be it the surgeon OR the resident.

 

[lealea1005]

okay so let me rephrase....is it odd that there are not daily physician dictation whether be it the surgeon OR the resident.

If the Physician intends to be paid for their services, there must be documentation that the service was provided, each time it was provided. There should be an attending's note for each time s/he saw you. There should also be a note made by the Resident Physician wach time s/he saw you. That note may be incorporated as part of the same section of the chart . Is that clearer?

You can always personally go down to the medical records department of the hospital with the package they sent you and ask about what you think may be missing.

 

[taddles]

yes much clearer thank you