Medical Records

medical-records

In an online bipolar support group, I recently posed the following questions:

How many of you request copies of your medical records? If you do read them, how do you feel about what you read?

I have requested records three times (and received them twice…still waiting on the third batch).  The first time was in March, immediately out of my first stay in the IPU.  Aside from general curiosity, I wanted some specific information that had not been shared with me: my exact diagnosis and the results of my first-ever blood tests.  I got my answers, and a few moments of humor, and a few other moments of being really annoyed.  For one thing, my appearance when I arrived at the IPU was described as “bizarre”.  I showed up clean, in dressy clothes and full makeup, and just happened to have purple hair.  This is not bizarre.  In fact, it was quite pretty.

I also was annoyed that every time someone did an assessment of my intelligence, they wrote down “average”.  The staff members who have seen me over the long term would definitely laugh at the thought of me being average.

A few months later, in late May, I submitted a request for everything added since that first batch.  The day before they arrived, my therapist told me she had been notified of my request in case she had any concerns.  I would still receive the records either way, but she did tell me she was concerned that as a people-pleaser I may read things as criticism that weren’t intended that way and become upset.  And possibly injure myself in response.  She made me promise that I would talk to her about anything in my records that upset me.

I tried not to be upset by anything.  I knew my reactions were irrational.  However, some things kept nagging at me, so when I next saw her I told her we needed to discuss it.  Most of my concerns were things she couldn’t really address since it was about other people’s notes.  The only thing I was bothered by in her notes was that she refers to me by name instead of as “the client” like my former therapist did, and I got a reasonable explanation as to why that’s done.

Last week I stopped in to submit another request, this time for the past 4 months worth of records.  Aside from being a longer time period, it is also one that was quite eventful, so I’m expecting a very large stack of papers, including:

  • Updated Adult Needs & Strengths Assessment (ANSA)
  • Updated treatment plan
  • 2 inpatient nursing assessments
  • 2 inpatient physicals
  • 2 admission notes to the inpatient unit
  • 2 discharge notes to the inpatient unit
  • 21 inpatient shift notes
  • 7 visits with inpatient psychiatrist/psych APRN
  • 3 visits with regular psych APRN
  • 21+ visits with regular therapist
  • 1 visit with therapist’s supervisor
  • 1 visit with on-call therapist
  • 1 phone call with a different on-call therapist

In fact, I won’t say “including”.  I don’t think I’ve missed anything, so if there are additional pages beyond a few more times seeing my regular therapist between now and when the records are printed, I think someone should take me out back and shoot me.

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One thought on “Medical Records

  1. Pingback: ANSAs to My Questions | Stuff That Needs Saying

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