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.

11 comments to Questions about my medical record

  • Amy

    If you are looking for your entire record, there should also be (depending on the policies of the hospital): Medication Administration Record (MAR), Nursing Notes (one per nurse per shift, so if on 12 Hr Shifts 2 per day), notes from ancillary services (respiratory, etc) if occurred, one doctor’s note per day and labs. Also maybe an anesthesiology record if not part of the OR record itself.

    [Reply]

  • I have no idea why it would be six pages unless maybe yours was a relatively uncomplicated operation.
    I have to say reading this makes me soooo not want a c-sec – the idea of my uterus being taken out of my body and then returned really freaks me out. I know they do it all the time, but wow.

    I hope your recovery is quick!

    [Reply]

  • So I guess I am missing a lot- ughhhh. I think the OB’s notes and the nurses’ notes are what I most wanted to read too. I’ll have to go back!! So weird she didn’t give them ALL to me when that’s what I asked for.

    Emily- I was in the hospital in labor for 24 hours before c-sec.. I’d imagine that deserves more than 6 pages! I hope for a vaginal birth for you too!!!

    [Reply]

  • Emily C

    Defintiely nurse’s notes and medications should be included in your medical records.

    [Reply]

  • Kristin

    That’s why so many women throw up during their c-sec, because the uterus is taken out of their body. I’m really surprised it’s only 6 pages but that could be all there was. I would get Ryan’s records as well. It does say that you had a second layer of sutures, so that’s a good thing. Most doctors do a double layer now, which puts you at a lower risk of uterine rupture.

    [Reply]

  • Yeah, six pages doesn’t sound right. My friend had scheduled cesarean and had just six pages of surgery notes.

    But, from the notes it sounds like you are primed for a VBAC! double uterine suture and the vicryl are both very good things!! All of it pretty much sums up to the fact you had the best incision for future labor and vaginal births.

    But I would definitely go back. If they say there isn’t any more, go to your doc’s office and get your entire record.

    [Reply]

  • Miracle Pending

    This definitely isn’t right. You should have a copy of all your prenatal exams also included in your chart. I saw my chart and it looked like a binder. Nurses take copious notes every time they see you (at least once an hour.) I know they enter all the information into their system as well as have a copy on file. Is there a way you can obtain the records without being in direct contact with your OB? This way she doesn’t have a way of interfering.

    It’s also odd that she didn’t charge you for the records. Usually you go through a copy service or need to give them a good amount of notice so that they have enough time to get ALL the pages copied.

    Here are your medical record rights

    If there are any discrepancies with even the information you have been given, you have the right to amend them. If your doctor does not give you the entire medical record, I would definitely complain it. At one point I didn’t trust my provider either so I took some time and told them I wanted to see the entire ORIGINAL file. Maybe you can do this so it would be easier to detect changes they may have made.

    [Reply]

  • ok reading this made me sick. I can’t believe they go into that much detail (which I mean, I can… they have to so like you said, they dont get sued) but gross. They way they describe every incision and cut.

    Definitely not my cup of tea.

    But reading all these other woman’s comments then I guess there is hope, since they say u r definitely ok to have a VBAC! 🙂

    [Reply]

  • Hi Emily,
    Here is all I know about your operative report.
    From the initial skin incision to the delivery of Ryan, everything was very normal. You didn’t lose a lot of blood, which is obviously very good for major abdominal surgery. As for the more important issue, Vicryl sutures are the best that you could have had. The alternative is chromic, which is associated with more uterine ruptures since it is thought to not be as strong. Chromic sutures lose about 50% of their tensile strength after 7-10 days (when the uterus shrinks dramatically) so they aren’t ideal if you want to VBAC since they might not hold. I’m not positive on this, but I remember reading somewhere that chromic sutures had a 3% chance of rupturing with a future VTOL whereas vicryl was the normally quoted .5-1% chance. So anyway, your doctor did make the right choice by using the vicryl but I hope anyone who had chromic won’t be discouraged. There are benefits and drawbacks to both types and I know many women who have had successful VBACs with chromic. Hopefully their doctor made the decision that was best for them.
    Another reason why you’ll be a great candidate for a VBAC is you had double layered suturing. There isn’t a ton of research on single layer versus double layer, and it definitely depends on the surgical skills of your physician, but generally double layer is thought to be better. The studied that have looked at single layer versus double layer have had fairly confusing results, in my opinion. Each really says something different. However, Ina May does not do VBACs of women who had single layer sutures at The Farm and she regularly speaks on how double is better than single. Personally, I think double is better, but that’s just me.
    So to wrap things up, so far it looks like you will have a great VBAC (or HBAC!) but so much depends on your pregnancy and the labor itself.
    Hope this helps!
    Allie

    [Reply]

  • OMG I can’t believe how they go on and on about “We discussed the risks and the alternatives!” WOW!! What jerks!! Well at least I know going into mine that I can ask them a gazillion questions and at least try to make that statement of theirs someone true (if it comes to that). Wow!!

    I hope you get the rest of your records if you need more! And I know what you mean about shopping makes you feel better. I was SO SAD yesterday after work and went strait to a consignment sale and felt SO MUCH better!!

    [Reply]

  • Okay, so it makes more sense to me knowing you had 24 hours of labour before the csec… I’m guessing they have an upper limit where they start to encourage a csec, as you were probably exhausted by this point!

    Still I am so sorry that you went through a procedure that you weren’t fully consenting to. It sounds (from reading the comments) like it hopefully will not affect your chances in future to have a vbac though!

    [Reply]

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