Question:
Help! Some of my dr's notes on my records are unreadable?
I have all of my medical records together and some of them you can't read, you can read my height and weight, but the rest looks like scribble, I even had someone who works in a Dr's office try and read it and she can't, will my insurance company deny me if they can't read all of the records? The ones I'm worried about are my dr's supervised diet. there is about 3 months that you can't read. Also I don't think she documented everything right, I told her what I needed but,I don't see where she wrote everything down, she did include most of the info in her letter, but I'm so worried. Does anyone who has gotten approved have any examples of what their doctors wrote? Her nurse said they can't write any additional info in my previous files, what does that mean? Have I wasted the last year? Please help!!! Thank you so much, Jen — jlflbf (posted on April 17, 2006)
April 17, 2006
Everyone knows that doctors can not write, but it is really up to you to
get notes that everyone can read. If you feel that it is all scribbled,
then you need to make the first move and call up the doctors. I am sure
the insurance companies have much experience in reading scibbled notes.
As for a recomendation from the PCP, most people I know had the surgeon
write the letters, and the PCP just wrote what he perscribed for you. I
think you need to sit down with the PCP and tell them your concerns
— Steve Cohen
April 17, 2006
thank you for your responce, before I posted I had just spoke to the nurse
at my PCP's office and she was so rude! I told her I just recieved all my
records for the last year and some of them weren't readable and also that
on some of the visits, my doctor didn't put reference to my diet/excercise
even though we talked about it everytime, and that I need all that info, so
if she could have doctor call me. She very rudely said what is in your
medical records can not be changed. I wasn't asking her to change them, I
just want all the correct info to send to the insurance company. I just
want this so much and have waited so long I want to have every i dotted.
Again Thank you for your response. LOL Jen
— jlflbf
April 17, 2006
I was rejected this week for the same thing. I always thought everything
that you discussed with doctor went in those files. But apparently that's
not so. It's just what the doctor wants to write in there. I now have to
wait 3 more months. Good Luck.
Donna P.
— donna0209
April 17, 2006
I wasted 9 months because the dr did not write down stuff, didn't even
document monthly weight. I tried to explain what I needed when I started
but it was not understood.
I finally made out a sample of what I wanted and the dr finally understood
it, but meanwhile, I changed insurance and didn't need it.
— geneswife
April 18, 2006
I worked with a Family Practice for years. It took about 9 months to be
able to read the Dr's scribbles. I also was the Hipaa compliance officer
when the announced Hipaa in 2003. According to Hipaa law you have the
right to examine your medical records and request that changes be made for
accuracy. Here is the Hipaa website. Check it out then call your doctor
again. http://www.hhs.gov/ocr/hipaa/
— Tiff
April 18, 2006
Jennifer, I don't know if I can help you, but I will tell you my story to
maybe help others just starting. A friend I know had your exact problem and
I knew this before hand. When I was doing my 6 month diet/weigh visits with
my pcp, I told them each visit what I was there for, and had the nurse
write that to start with. Then when the doctor/ nut. came in I again spoke
slowly and read over their shoulder and made sure what I thought needed to
be down, was there. Then I asked for a copy of that days notes before I
left. They just made me a copy right then. Was I a pain in the butt? yep,
but I was taking control of my pre-op and when I needed my 6 months notes,
I had them, just had to get the final letter and I was good to go. This
takes a little more time, but it was so worth it in the end. I guess what I
am saying is MAKE SURE each visit that the doctor writes in your chart what
needs to be addressed even if you have to gentley remind them at each
visit. My doctor was truely on board with me, and appreciated that I had
done my homework and was helping her to know what was needed so she could
help others after me. We have to take a very active role in getting
insurance to approve this surgery. Good luck to you, Don't give up!!
— Debbie M.
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