Doc: One-click medical records can contain errors

Keith Roach To Your Health

Dear Dr. Roach: I was a registered nurse for more than 45 years, and I admit that I am old-school. I specialized in emergency-room and cardiac care. I always ask for copies of my office notes and test results for my records, and I see a frightening trend among physicians. In the past five years, I have seen a surgeon, a cardiologist, an orthopedic surgeon and an emergency-room physician. All four of these physicians documented physical findings, such as “abdomen soft and nontender,” “normal eye, ear, femoral pulses, pedal pulses and reflexes,” without ever examining me. The documentation also consists of alleged statements that I never uttered!

Most doctors’ offices and hospitals have patient portals online where you can read your records and test results, and print them. My insurance company has access to my health records. Any one of these doctors could miss vital information because they did not examine the patient. I have no problem with an orthopedic doctor not checking my ENT or abdomen when I am complaining of knee pain, but I DO have a problem with them falsifying my medical records by entering physical findings for systems they did not examine.

M.M.

M.M.: I, too, am “old-school” and feel that patients deserve the physical exam appropriate for their situation. What’s more important, documenting physical findings that weren’t actually done is fraudulent, and even worse, can lead to errors in your medical care.

I don’t excuse these behaviors in any way, but I do think that they are very easy to make when using electronic medical systems that enable a physician to document a complete exam with all normal findings with a single click. These systems are great for helping with billing, but have significant potential for abuse, with the potential for real medical harm to patients.

If you find an error in your medical record (and I do recommend looking at the information via patient portal), then you should bring it up with the physician, who should amend the record to reflect the true medical situation.

Dear Dr. Roach: I have had elevated liver enzymes for about a year now. Every blood test shows that my ALT is 48 U/L and my AST is 51 U/L. My doctor had me get an ultrasound of my liver, and it looks good. I also had a CT of my pancreas, which looks good. I am a 62-year-old female with a BMI of 31.5 and a waist circumference of 38. I am 5 feet, 10 inches tall. Could this be cancer at its earliest stage? Cancer is prevalent in my immediate family. Please shed some light on this.

J.B.S.

Dear J.B.S.: In most labs, the ALT and AST (commonly obtained tests of liver function whose levels are increased with many kinds of damage to liver cells) have an upper range of normal for women of about 35, so your degree of elevation is very mild. Your body mass (31) and waist circumference (38 inches) put you into the “overweight” range, and I suspect that a lot of your excess weight is in your abdomen. These put you at risk for fatty liver, which I think is the most common cause of elevated liver enzymes. Very mild amounts of fatty liver might not have been picked up by the ultrasound.

There are many, many other causes. Alcohol use (even fairly modest), viral hepatitis, many medications, celiac disease, hemochromatosis and alpha-1 antitrypsin deficiency deserve consideration. I can’t tell you that it’s impossible that you have early cancer, but it’s unlikely.

Email questions to ToYourGoodHealth@med.cornell.edu.