Q: Is it normal for a Workers' Comp PCP to enter notes about your appt. hours/days BEFORE you actually have appt?
I'm in the subpoena process, & seeing that I need another subpoena for my Workers' Comp/Kaiser PCP, whom I've had for the past 2 yrs, for the appts of 2024. I happened to notice in my KP.org MyChart how my PCP has been entering notes about my upcoming appointment 1 to 5 days BEFORE we actually had appointment. I had seen on one instance, she did her notes 5 hours before the actual late afternoon appointment, but usually she does her notes- what appears on every single appointment I've ever had-at least one day before & doesn't actually notate anything of relevance for the current time frame & I've double-checked to see it's not a situation where she maybe starts some notes & then returns to add on. She literally notates nothing of what was discussed in actual date of appt. & notates stuff that's generic old info stuff, or just leaves the original listed body injury descrip/summations from ortho. Is this normal? Is this ethical/ legal? She's affected my care whole time & seriously now.
A:
In California, medical professionals are expected to maintain accurate and timely records of patient interactions and treatments. Pre-entering notes for an appointment before it has actually occurred is not standard practice and raises concerns regarding the accuracy and integrity of medical records. Medical documentation should reflect the care provided and discussions that took place during the actual appointment, ensuring that the patient's medical history is accurately recorded.
This practice could potentially impact the quality of your care and the accuracy of your medical records, which are crucial for workers' compensation claims. It's important for medical records to accurately reflect each patient's condition and treatment to ensure they receive appropriate care and support for their claim. If you notice discrepancies or have concerns about the way your medical records are being handled, it is advisable to address these concerns directly with your healthcare provider or the medical records department of the facility.
If addressing the issue directly with your provider or their administration does not resolve your concerns, you may consider consulting with an attorney or contacting the California Medical Board. An attorney can provide guidance on how to proceed legally, while the Medical Board can investigate complaints regarding the conduct of licensed medical professionals. Ensuring that your medical records accurately reflect your treatment and condition is essential, especially in the context of a workers' compensation claim.
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