What Dr. says vs. What he writes

[calli66]

I just got my med records from my dry eye doctor. Was a bit surprised by the notes---more info in them than the doctor ever imparted to me during the appointments.

His notes included "meibomitis---may contribute to symptoms." (stating the obvious----but the only thing he said to me was "your eyes are extremely dry---do you want me to insert plugs?").

Under the heading "Review of Symptoms," sub-heading Psychological, it says "low mood--irritability." (I hadn't realized the techs made comments like this).

He wrote, "meibomian gland dysfunction & margin vessels, 2+, and conjunctivochalasis," both eyes, "punctate epithelieal erosions, meager tear meniscus, tear film breakup time-decreased with tear film debris." "Patient states she still has the same floaters that come and go. The patient denies flashes." I just LOVE that---the "patient DENIES"---OMG, I was being interrogated and I didn't even know it! Is this normal doctor's office English? It's just weird, that they use this word "denies" just to mean "does not" or "not present." It's like they assume you must be holding back information and lying to them.

The good thing is, that those notes were from October of 2007, and since then, I've been doing all the self-treatment (eye spa, scrubs, etc) on my own, without knowing whether or not I had meibomian gland dysfuntion, or PEE (the punctate erosions), etc. And I'm much better now.

My take-away lessons: 1) to be a bit more careful what I say to techs and doctors; and 2) ask the doctor to be more specific in terminology---and explain to me their impressions and diagnostic terms.

Thanks for listening to my whine today!

Calli

[Rebecca Petris]

I just got my med records from my dry eye doctor. Was a bit surprised by the notes---more info in them than the doctor ever imparted to me during the appointments....

My take-away lessons: 1) to be a bit more careful what I say to techs and doctors; and 2) ask the doctor to be more specific in terminology---and explain to me their impressions and diagnostic terms.

Wow - glad that you got the info eventually anyway. Yes doctors notes can be surprising, in good and bad ways!

I have seen/heard a lot of quite offensive things in notes put into people's records in dry eye and also in lasik cases, but personally, I would not be fazed by that use of the word "denies". When it's regarding something they can't verify by objective examination, I think that's just medicalspeak for "when asked, says they don't have xxx symptom" as opposed to "I suspect she has it but won't admit it".

[Lucy]

What Rebecca says. "The patient denies.............." is a routinely used phrase which I believe only means you say you don't have this particular thing (symptom/problem/etc.). I just about tore a doctor's head off a long time ago and it was not anything to do with eyes. I think it was "patient denies blah, blah, blah,." It was just their jargon to rule things out. It certainly isn't a way I agree with.

I've found stuff in my eye dr's filed that had no place in there. Way beyond what a technician is trained and authorized report. Calli, I'd be more sensitive to those parts of the record than the part Rebecca spoke of.

Darn docs. Lucy

[kitty]

I'm a nurse. "Denies" is routine and customary language. Like when your family doctor reviews each body system when taking your history. He/she may ask "Are you having any pain in your chest?" You say "no". Dr. writes, "denies chest pain". Nothing negative at all implied by this. I would be more concerned about all of the diagnoses and whether or not those were discussed with you. I'm a firm believer that patients should ask what diagnoses they have. Patients have to be informed health care consumers these days. I'm glad you are doing better!

[calli66]

kitty,

I kind of guessed that "denies" was medical-speak---just sounded very strange!

I would certainly have been more informed if the doc had explained things. I remember even asking during the exam what he thought of my meibomian glands, and he didn't respond at all. Go figure. And he was a doc that I felt positive about.

He was always terribly rushed, though. Maybe I've told this story before here, but I remember at one appointment he came flying into the exam room so fast, that when he sat down on the rolling doctor stool, he skidded out on 2 wheels and landed on the floor. Shoulda hadda camera. I was a good girl and didn't laugh.

C

[kitty]

kitty,

I kind of guessed that "denies" was medical-speak---just sounded very strange!

I would certainly have been more informed if the doc had explained things. I remember even asking during the exam what he thought of my meibomian glands, and he didn't respond at all. Go figure. And he was a doc that I felt positive about.

He was always terribly rushed, though. Maybe I've told this story before here, but I remember at one appointment he came flying into the exam room so fast, that when he sat down on the rolling doctor stool, he skidded out on 2 wheels and landed on the floor. Shoulda hadda camera. I was a good girl and didn't laugh.

C

That is too funny!

[Lucy]

He was always terribly rushed, though. Maybe I've told this story before here, but I remember at one appointment he came flying into the exam room so fast, that when he sat down on the rolling doctor stool, he skidded out on 2 wheels and landed on the floor. Shoulda hadda camera. I was a good girl and didn't laugh.

This was worth this thread by itself. I have seen some docs whom I can imagine doing this. My ophtho isn't one though. Thanks for the laugh. Lucy

[Rebecca Petris]

He was always terribly rushed, though. Maybe I've told this story before here, but I remember at one appointment he came flying into the exam room so fast, that when he sat down on the rolling doctor stool, he skidded out on 2 wheels and landed on the floor. Shoulda hadda camera.

Wow! What glorious footage that would have been... I can just see a cheeky caption of some sort on it about the nature of 21st century "health care".