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Dr. Wander, Dr. Ed, Dr. Z. - Medical Records

Posted by Darlene on 1/09/05 at 11:51 (166783)

I requested my medical records from my failed nerve decompression surgery. I received the Operative Report only. I was told before the surgery that the likelihood of success was 90%. I was shocked to read in the Operative Report under the section for Prognosis to read 'Guarded - due to length of pathology.'

What do you think?

Re: Dr. Wander, Dr. Ed, Dr. Z. - Medical Records

Dr. David S. Wander on 1/09/05 at 12:25 (166784)

First, I would contact the office again and request your entire set of medical records, not bits and pieces. There may be a fee for these records, but you have a right to copies of your complete records. If the office plays hardball with you, I would contact an attorney and/or the local medical or podiatric medical society.

The comment on the operative report stating 'Guarded-due to length of pathology' should not be a major concern. The doctor probably included this in the report as a 'CYA' (cover your ass)in the event the surgery was not successful. Naturally, this should have been consistent with what he told you (likelihood of success 90%), but it apparently differs. This is something you may want to talk to him about.

Regardless, be persistent and obtain ALL your records. These will be useful for any subsequent treating doctor.

Re: Thank you Dr. Wander

Darlene on 1/09/05 at 15:05 (166797)

I appreciate the time you took to answer this and my other questions.


Re: for Darlene

Linda V on 1/09/05 at 15:31 (166800)

I used to work in a medical records office. Every office has its own unique policy. Ours was that if a DOCTOR or other medical facility requested the records..no charge. If the PATIENT wanted them, it was $2.00 a page. If an ATTORNEY wanted them, it was $20.00 a page. So...if you have another doctor you are working with now..it might be better if HE asks for them. You also have the right to review ANY of your records, but this might be by appointment only, as it is often wise to have some sort of medical person with you to help interpret them.

Re: for Darlene

Dr. Z on 1/09/05 at 19:02 (166805)

You would do much better to have the treating doctor request them if he wants them. The most importance thing at this stage is to go your foot better. Is you current treating doctor tell you he needs your records, so sign a release and have him or her request the medical records
I wouldn't waste too much time with getting all of the records at this point. Try to find someone to help you with your current treatment. I rarely request or need additional records except for the operative report

Re: Thank you Dr. Z.

Darlene on 1/09/05 at 19:21 (166806)

Yes - my main priority is to get better. It is almost 1 year since the failed surgery and I really want to get my life back. I am having surgery this week.

Wish me luck.


Re: for Darlene

Darlene on 1/09/05 at 19:22 (166807)


Thanks for replying. Interesting about the $20 per page. I guess it is more expensive to photocopy for an attorney:).

Re: Thank you Dr. Z.

Dr. David S. Wander on 1/09/05 at 19:26 (166808)


I agree with Dr. Z regarding making your recovery a priority, but I strongly disagree with his statement that the operative report is all that is required. I like complete records, to have a complete history of conservative treatments as well as any documented post operative complications. It also allows me to have a documented chronological order of events, tests performed, etc. These are the 'blueprints' that allow me to offer the best treatment plans for my patient. The operative report only offers the events of one day out of months or years of treatment.

Re: Thank you Dr. Z.

Dr. Z on 1/09/05 at 21:50 (166818)

Dr. Wander,
If I waited for COMPLETE records on every patient that came to me with complications from foot surgery and requested medical records I would be still waiting. Many of my patients have been to mulitple doctors, had multiple treatments, in pain for years, etc, etc. Sometime your blueprints are best made with an in depth physical examination along with an experienced doctor, who has excellent communication skills.
What I would suggest to patients is to keep their own medical records at home and take them with you.

Re: Thank you Dr. Z.

Dr. Z on 1/09/05 at 21:51 (166819)

PS: If you doctor is concerned about past treatments and how it will effect his future treatments. I like to pick up the phone and talk to the doctor