Questions about my medical record

Alright, I stopped by the hospital today and picked up a copy of my medical records. I got there at like 5 minutes to 5pm so I was just glad they took my request when the office was closing soon.

I asked for everything. She said, “from the whole hospital stay when you were here for the birth?” I said yes. She came back and handed me an envelope and said it was everything. So I took it and left. (I’m assuming they’ll bill me for them? I find it funny she didn’t tell me that).

Anyway… I have diddly squat. One woman on twitter said hers was 30 pages, another said 200. Mine? SIX PAGES. I think she screwed me over. But I have no idea what else should be in here… ok, this is what I was given:

• Operative Record (3 pages, but the last one is blank)
• Discharge Summary (1 page)
• Clinical History and Physical (2 pages)

And there’s really nothing of interest. Except the discharge summary does not match the clinical history (discharge says I got to 0 station, history says I got to +1) And I am certainly positive the OB told me I was at +1. Reason for surgery? Failure to progress. The OB’s operative records says “arrest of descent” and “arrest of dilatation.”

So am I missing papers?? Nurse’s notes?? Doctor’s notes?? Or is this really all of it??? If this isn’t all of it, when I clearly asked for ALL of it and she repeated it… I’m totally pissed. The hospital is 25 minutes away, I work, I  have a baby… I’m so annoyed and upset I have to go all the way back out there. And so annoyed I don’t get all my answers right now. I was prepared for them (I think). I decided I had to do something to make myself happy so on the way home I stopped at Michaels to get Ryan’s Easter basket and then at Starbucks for my favvvvorite: grande no-whip non-fat iced white mocha. And it really did work… it made me happy 🙂

And I could use some help with all this incision lingo in the operative record (oh let me point out how hilarious I find the way these records are written–to very clearly keep them from getting sued):

After informed consent was obtained and all questions answered, the patient was taken to the operating room where she was placed in the dorsal supine position with a rightward tilt. She was then prepped and draped in a normal sterile fashion and a Pfannenstiel skin incision was then made with the scalpel and carried through to underlying layer of fascia. The fascia was incised in the midline and the fascial incision was then extended laterally with the Mayo scissors. The superior aspect fo the fascia was grasped with the Kocher clamps, elevated and rectus muscle dissected off bluntly and sharply. The inferior aspect of the rectus muscles were separated in the midline and the peritoneum was then entered bluntly. The peritoneal incision was then extended superiorly with good visualization of the bladder. The bladder blade was then placed and the bladder flap was then created sharply. The bladder blade was then once again replaced. A low transverse incision was then made into the uterus with the scalpel and this incision was then extended laterally bluntly. The infant’s head was then delivered atraumatically followed shortly by the body. The cord was double-clamped and cut and the infant was passed to the waiting neonatologist. The placenta was then removed manually and the uterus was exteriorized, cleared of all clots and debris. The uterine incision was then repaired with 0 Vicryl in a running lock fashion. A second suture of 0 Vicryl was used for an imbrication stitch for excellent hemostasis. The posterior cul-de-sac was then irrigated, cleared of all clots and debris. The uterus was then returned to the abdominal cavity. The gutters were then irrigated and cleared of all clots and debris. The uterine incision was then once again inspected and found to be hemostatic. The fascia was then reapproximated with 0 Vicryl in a running fashion. Subcutaneous tissue was then irrigated, cleared of all clots and debris and then made hemostatic with electrocautery. It was then loosely reapproximated with 3-0 Vicryl. The skin was then closed in a subcuticular fashion with 4-0 Vicryl. The patient tolerated the procedure well. She received preoperative antibiotics and had bilateral SCDs on during the course of the procedure. She was taken to the recovery room in stable condition.

And from the Clinical History & Physical:

…She was expectantly managed until about 12:30 at which point she consented to having her water broken [hm, they don’t mention the fact that it was because they told me they thought I had an infection]. Clear fluid was obtained at that time. The patient continued to be expectantly managed with minimal change and was started on Pitocin about 3 hours later. The patient subsequently continued on Pitocin augmentation until about 2:50 on the morning of 12/26/2009 [type, it was 12/27] at which point her cervix was noted to be 8 cm dilated, 90% effaced, cephalic in presentation, and +1 station. This was an unchanged cervical exam for the past 4 hours [SO NOT TRUE. Maybe the past 2 hours.] The fetal heart tones were in the 150’s with moderate variability and positive accelerations. There were no decelerations most noted, and she was contracting every 2 minutes on 24 milliunits of Pitocin with MVUs between 160 and 190. Given no cervical change, despite adequate MVUs, a primary c-section was recommended for delivery.

PLAN: The plan at this point is to take the patient to the operating room for a primary cesarean c-section for arrest of descent and arrest of dilatation. The risks and benefits of the surgery were discussed with Ms. Dickey including risks of infection, bleeding, injury to the baby, injury to pelvic organs [I’m sorry, but this is bullshit]. We discussed the alternative as well. [Discussed??? Nice word choice.] Ms. Dickey has consented for the procedure. All of her questions were answered. She will receive clindamycin as antibiotic prophylaxis. She will have bilateral SCDs as well.