Question Regarding My Medical File. What Does This Mean?

Question

I went to Planned Parenthood to get birth control pills to treat Endometriosis (Thought I would get them cheaper but actually they are about the same there.)

Anyways,

I am looking at the copy of my file that I requested. It has a section titled "Counseling/Education Given"

There are various topics listed with an option to check off each one. The clinician checked Safer s*x, Smoking risks, EC discussed/ Offered, STI/HIV Risk Reduction"

However, she never discussed any of those topics.

My question is: At the top of this box it says "Copy of Consents" and then the choice of "Given" and "Declined". What does that mean? I don't recall declining anything. I always accept all the papers they give me.

Thanks for any advice! It is greatly appreciated

Answer 1

Any time you visit a health care professional they have to document the care they provided. A hallmark phrase is "If it isn't written, it wasn't done." In addition to documenting the care given,  teaching the patient about self-help, interventions, etc. is required, thus the check-off categories on the page in your medical record. Unfortuntely, several things could have happened: either the practitioner didn't teach you what s/he documented, you didn't understand what the practitioner was saying, or the practitioner didn't explain it in terms you could understand, and obviously didn't ask you if you understood.  

Answer 2

It means that she was supposed to give you pamphlets with information on all of these topics, or at least offer them to you and you have to choice to accept or decline her offering...

If she checked these topics, she should have talked with you about all of them...If she didn't and you feel that you were mistreated, i would talk to the clinic about this.  These are topics that many ppl who go to Planned Parenthood need information on...

On another note, if you need help paying for BC, there is federal aid that will help-- if you make less that $17,000 per year its free.  Google BE smart, family planning.  Fill out the paper and take it to your local social services office or health dept. and you can get BC free...i think as long as you are 16-65 you can get free BC from your health dept too?? check into this!

Answer 3

I am a nurse, but not an OB/GYN nurse.  But standards of practice is in effect for all of us.

If the clinician marked these and did not discuss or give you copies, it is falsification of documents.

As a patient you have a right to all parts of your chart.  At your next appointment, discuss this with her, ask her for any copies listed, and tell her you want to know about the topics she checked.  

You are the patient. Anything written, any tests, and results are yours and you have a right to them.