Medical Notes Reports and Prescriptions

A few days ago cleaning my basement I found some old medical notes my pediatrician wrote after physical examinations I had undergone about 30 years ago.

I reported here some:

"Weight kg 55 , body lenght 151 cm,

General health conditions: good.

Development of genitals: G4 P4.

scrotal venous plexus normal.

Malocclusion."

"Weight kg 52, body lenght 146 cm

general health conditions: good

testicular volume normal,

remissive phimosis of the penis"

"General health conditions: good

Development of genitals: G3 P3

Phimosis of the prepuce, distension therapy, applied Clobetasol

pharyngitis"

"General health conditions: good

Development of genitals: G3 P3

Phimosis, dorsal glans hyperemia, referred for surgical option,

pharyngitis"

Reading dates, the address of the doctor office and medical details (about Tanner staging and orchidometric, phimosis exams etc I never read because I was too young at that time) lets some memories comes to my mind.

Do you have similar notes/reports/prescriptions you want to share ?

I have wondered if nurses or doctors take liberties to write down observations of an exam that reflect more of their personal biases aside from the basics? It certainly is the stuff for medfet fans to wonder an likely imagine what's written.

43 married white male seen for initial exam; new to the area and seeking a primary care doc.

Pt. shy and reserved when told to undress. Weight 150; Height 5'4".

Briefs were subsequently lowered for rectal temp; pt fussed and developed an erection during temp registration.

BP, Heart, lungs and abdominal exam WNL.

Genital exam consistent with normal but small penis. No abnormal findings upon testicular exam. Slow to become erect.

Rectal and prostate exams WNL; Pt. fully erect with rapid ejaculation upon prostate exam.

IM tetanus given; Pt. protested and whimpered during administration.

Overall excellent health.

Pt. to return for F/U with enema clean out.

You can be assured, Drs and nurses record everything. Even things you say in quotes if inappropriate

When I obtained a copy of my medical notes, they made for enthralling reading, most definately worth the fee

I'm very careful to not say anything I wouldn't want in my permanent record.

I'm very careful to not say anything I wouldn't want in my permanent record.

My doc and I talked politics or whatever was going on at the moment. I highly doubt any of that makes it into the chart. As a matter of fact I watched him write his notes and he was asking me medical questions as he jotted them down. I really don't care what he puts in the record but I have no fear of anything of a personal nature other than medical being in there. He recently passed away so I am starting over

When I obtained a copy of my medical notes, they made for enthralling reading, most definately worth the fee

@cutmedfan: How far back did they go, and what form did they take? Photocopies of original notes or summaries?

I am extremely blessed to have a close relationship with my doctor/gynecologist and I consider him a good friend. I never worry about what I say in his presence because I know everything I say is safe with him. As they say doctor/patient confidentiality. He honors that because there are things I have said that have never made that file because he told me they would not. He is good at what he does and honors my wishes as well.

I hate to confess, but when I was a medical social worker, my reports in the chart, hand written and only had stuff that I decided was “fit to print” made it through to the progress notes. But no one knows what I heard and saw that stayed in my own mind. I might not remember the name, but the face and story is always there. I might remember that your brother lived in Red Deer and much of history of your history but the your name alludes me.

btw - being a Registered Social Worker I was bound by some laws and prof. ethics.

I would read them their rights. In the end those stories, who ran off with with whom and so on stayed in my head.

I still have them in my head.

@toshe63 said

You can be assured, Drs and nurses record everything. Even things you say in quotes if inappropriate

It doesn't sound like people who write all that crap down have the patient's best interest or privacy at heart. Those people give a bad name to nurses and doctors.

.

@superego said

I hate to confess, but when I was a medical social worker, my reports in the chart, hand written and only had stuff that I decided was “fit to print” made it through to the progress notes. But no one knows what I heard and saw that stayed in my own mind. I might not remember the name. The face and story is always there. I might remember that your brother lived in Red Deer and much of history of your history but the your name alludes me.

btw being a Registered Social Worker I was bound by some laws and prof. ethics.

I would read ‘em there rights. In the end those stories, who ran off with with whom mand so on stayed im my head.

I still got’em in my head.

It's nice to know some people still care about the patients and their privacy.

Legal mandates or not, I would never write anything in the chart that the patient said that I thought was inappropriate because I value the doctor/patient confidential relationship.

I just had to find a new doc as the old one suddenly died. I have 30 years worth of records and I haven't seen one personal thing in any of it. Unless they think you have a screw loose I don't think they are going to put anything in there of a personal nature.

@Nick321 said

Briefs were subsequently lowered for rectal temp; pt fussed and developed an erection during temp registration.

normal but small penis. Slow to become erect.

Rectal and prostate exams WNL; Pt. fully erect with rapid ejaculation upon prostate exam.

IM tetanus given; Pt. protested and whimpered during administration.

Any of these things happening during an exam is about as important or noteworthy as the patient sneezing while being auscultated.

The person who wrote this crap in the patient's chart is an idiot.

I just had to find a new doc as the old one suddenly died. I have 30 years worth of records and I haven't seen one personal thing in any of it. Unless they think you have a screw loose I don't think they are going to put anything in there of a personal nature.

That may have been THEN.

I am sorry to say there are more self righteous "do gooders" and trouble makers now in the medical profession. Just look in other threads where people think they are helping by telling people things that don't change their life and that they don't need to know.

Things are NOT like they used to be.

I used to read through my medical records frequently and the full reports are still sent to me a couple weeks after the appointment. Because I can now see everything I need on the online portal, the hard copies are stored away in a binder organized by date and tabbed for notable events (new/changed diagnosis, hospitalization, major medication change, etc.). I do not read them as closely as I used to, but skimming them there is nothing in them that I do not think should be there. The only personal information is a 1-2 sentence summary of how I describe what I have been doing recently such as working more/less hours or a fun event I am looking forwards to or already attended.

At the very least it helps my doctors be more personable with me. It can also help gauge how my physical symptoms are impacting my activity or where I am at mentally.

Never in any of said records have I seen something recorded that I feel shouldn't have been in terms of inappropriate comments or reactions. That is exactly how it should be.

Your medical records are a legal document. They do not belong to you but belong to the legal name of the practice. For the most part anything you say and how the dr. or even the nurse writes it down or it is transcribed and he/she signs off on it it is then a permanent record. And for the most part within a practice employees who had access to the charts, when they were all paper, we could look and read anyone's chart. So the young female patient that came in with some rectal bleeding because she had a guy force her to have anal sex was documented and there to be read by anyone who knew which patient it was.

So today be careful what you say to anyone in the medical office, hospital or surgery center and so on because it can become part of your permanent record and digital records are absolutely forever.

Your medical records are a legal document. They do not belong to you but belong to the legal name of the practice. For the most part anything you say and how the dr. or even the nurse writes it down or it is transcribed and he/she signs off on it it is then a permanent record. And for the most part within a practice employees who had access to the charts, when they were all paper, we could look and read anyone's chart. So the young female patient that came in with some rectal bleeding because she had a guy force her to have anal sex was documented and there to be read by anyone who knew which patient it was.

So today be careful what you say to anyone in the medical office, hospital or surgery center and so on because it can become part of your permanent record and digital records are absolutely forever.

That is all true.

Patients do not own their medical records, but they are entitled to a copy of their records.

I have not been to a doctor in 45 years.... not much to read ! hopefully my autopsy video and report will be interesting ! as i have been totaly drug free and cleaned the colon everyday i have discovered ways to hotrod the body and i love it. i have the best innerds and there beautiful and smart the enteric system can learn and can teach

That is all true.

Patients do not own their medical records, but they are entitled to a copy of their records.

Patients do not own the physical or electronic records (except in New Hampsire, where they do), but they do own the content and have the legal right to make changes.

@AndrewStephenWood, my notes went all the way back to my birth, and consisted of photocopies of the original notes from the GP, and Hospital

Patients do not own the physical or electronic records (except in New Hampsire, where they do), but they do own the content and have the legal right to make changes.

I don't believe they have the right to make changes, because those are the words of the healthcare provider. But in some states they have the right to include statements if they believe something is incorrect.

Insurance records are a whole other issue.

You can annotate or add to the record but you cannot change what the practitioner has written.

Notes from one of my gyn exams:

OBJECTIVE/PHYSICAL EXAMINATION:

BREASTS: Negative and anodular bilaterally. ABDOMEN: Soft. Liver, kidneys, and spleen are not palpable.

GENITALIA: External genitalia are clean. Vagina is clean. Cervix is pink and nulliparas. The uterus is enlarged, irregular 6 to 8 week size. Adnexa is negative bilaterally.

IMPRESSION: Leiomyomata and menorrhagia.

From my abdominal ultrasound after hysterectomy:

Ultrasound interrogation of the abdomen is provided for interpretation.

Liver is homogeneous without focal mass lesion. There is no intrahepatic biliary ductal dilatation. Hepatic vein confluence appears unremarkable. There is normal caliber portal vein with hepatopedal flow within the portal vein.

The gallbladder is normal. The common bile duct at the porta hepatis measures 4 mm and is normal in size.

The pancreas is normal.

The right kidney measures 11.5 x 5.3 x 5.5 cm. The left kidney measures 11.3 x 5.3 x 4.5 cm. There is no renal mass lesion. There is no hydronephrosis.

The spleen measures 11.9 x 5.0 x 12.4 cm.

There is no abdominal aortic aneurysm.

Impression: Unremarkable abdominal ultrasound.

Here's one of mine:

Well. 1yr.

I'm not sure that standard of recording would be acceptable 30 years later.

Here's one of mine:

Well. 1yr.

I'm not sure that standard of recording would be acceptable 30 years later.

Succinct! Back then handwritten summaries were understandably short!