Two weeks ago I was riding my bike in my neighborhood, and in an attempt to avoid being hit by a car that was backing out of a driveway, I rode my bike from the street up onto the sidewalk. In so doing, I had to squeeze past a dumpster that was halfway on the sidewalk in my path. The space between the dumpster and a rocky yard was too narrow, and I somehow rammed my little finger into the dumpster and broke it at the base of the lowest joint. I nearly fell off the bike but was able to stay upright in spite of an extremely painful left hand!
By the time I got home, the little finger on my left hand was already swelling, and the pain was unrelenting. I decided it was best to go to Urgent Care, and I was waiting outside when their doors opened.
After filling out some paperwork about my insurance, I was eventually led back into the bowels of the Urgent Care where my vital signs were taken. I was then escorted to a small exam room to wait for the physician's assistant. No physician was in the facility that day. The PA came in, looked at my finger, and told me I would be taken to X-ray shortly. At no time did he or anyone else ask me how the injury was incurred and when it happened. No one asked me to rate or describe my pain.
When the x-ray results were obtained, I was told to see an orthopedist and was given a printed copy of the x-ray results along with a CD of the x-ray image to take to the doctor. For some reason, neither my primary care physician nor the hand specialist I eventually saw were able to download the images on the CD.
It wasn't until after I left the urgent care that I read the history written by the PA. According to the history, the accident had occurred the previous day when I supposedly fell. In reality, it had happened that very morning, and there had been no fall. The PA wrote that my pain was severe (though it was mild and intermittent by that time) and he described it using several inaccurate adjectives. In short, the history was a complete fabrication.
In my book, I encourage the patient to ask the nurse to either read the medical history contained in the patient's chart or provide a printed copy so the patient can check it for accuracy. An inaccurate history can result in a misguided focus, inappropriate or unnecessary treatment, and influence future visits to the physician or hospital. An inaccurate history can even adversely affect potential litigation in some cases.
I failed to take my own advice to read the history before leaving the facility, but I hope that you will take my advice and remember to make sure your medical history, as recorded in your permanent chart, tells the true and accurate story of you!
