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.