(July 16, 2023) There IS a way to correct your medical record. . .but it requires a little bit of work.

It’s all explained here, in the Checkit portion of The Guide to Getting and Using Your Medical Records, brought to us by the Office of the National Coordinator for Health Information Technology :

https://www.healthit.gov/how-to-get-your-health-record/check-it/#:~:text=If%20your%20provider%20has%20a,where%20you%20found%20the%20mistake.

So, after fulfilling Steps 1-4 and, not surprisingly, receiving the Notice of Denial, I prepared my Written Statement of Disagreement with the Denial and requested that it be attached in its entirety to all future disclosures of protected health information (PHI). It was sent by certified mail to Linda Houck, RHIA, CTR, Executive Director of Health Information Management and Cancer Registry Services at RCCI, Elm & Carlton, Buffalo, NY, and reads as follows:

“Shipra Gandhi, MD, and/or providers who work for and with her apparently short-cut the time they spend in charting visit results. This is evident in the practice of block-copying information from prior notes into subsequent notes without bothering to check its veracity. Such haste may permit more practice time but it also, unfortunately, distorts the resultant PHI.

This is unacceptable.

One example occurs in the physical examination section. At my first visit the resident performed a complete physical exam, noting that my abdomen was “soft and nontender.” At that time my abdomen was (and remains to this day) extensively scarred and appropriately tender due to multiple surgeries and significant intestinal loss resulting from typhlitis. Nonetheless, the examiner’s erroneous assessment (plus the remaining portion of his physical exam report) is replicated on each subsequent visit note, even though a complete physical examination has never since been performed.

This leads to another, more troublesome error. The notes read “The patient changed her care to Roswell Park due to a bad relationship with her doctor.” This is incorrect. The statement should read “The patient changed her care to Roswell Park due to her prior oncologist’s failure to diagnose the hallmark symptoms of typhlitis.”

At no point did I ever assert a “bad relationship with [my] doctor.” When queried as to why I switched care from Ajay Dhakal, MBBS (Pluta Cancer Center) to the doctors at Roswell, my consistent answer has been “because Dr. Dhakal nearly killed me with incompetence.” Clearly, I sought medical care elsewhere because I had (barely) survived his one attempt at killing me, and I didn’t want to give him a second chance.

The information pertaining thereto is verified in notes from the University of Rochester Medical Center and Highland Hospital, copies of which my providers have in their possession but apparently refuse to consult. Instead, they choose to protect Dr. Dhakal from his misdiagnosis by ignoring my statements, claiming that the transfer of care resulted from “a bad relationship with her doctor.”

I vehemently resent that this near-fatal experience and its ongoing sequelae are misrepresented and dismissed as something of no medical consequence and therefore should never be mentioned again, much less documented in my chart. I further resent the implication that it was caused by “a bad relationship with [my] doctor” when in truth it was entirely iatrogenic – because, when apprised of my symptoms of fever (103 degrees F), intense abdominal pain, and “throwing up brown stuff,” Dr. Dhakal advised “This is only day 8. Wait 4 days. By day 12 you will feel much better.” (By day 12, I was near death, had 2 emergency surgeries, and ended up on life support.) Reducing this part of my past medical history to a condescending blame-the-victim comment is an unscrupulous misrepresentation of fact and as such has no place in a medical record.

Good advice. I should send a copy to Ajay Dhakal.

I expect my medical record to represent what occurs in the office between my provider(s) and myself without the taint of misinterpretation, bias, and/or misplaced professional fealty. I am appalled that my record has been twisted into an instrument that protects Dr. Dhakal from himself and horrified that it forces me to protect him as well, albeit indirectly. This I refuse to do, hence this Written Statement of Disagreement with the Denial.”

A bit lengthy, perhaps, but it clearly documents the facts and tells why the record should be corrected. Besides, it doesn’t matter how long the correspondence is, it’s still only $4.68 for certified mail.

I think this is the best $4.68 I ever spent!