Deleting notes

[psychma]

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I ordered inpatient notes from a client I was assessing. They came without any psychiatrists notes. I called over to the psychiatrist and he told me he had them removed because the client had sent him a letter explaining why each note had facts missing and argued with him. He told me who to ask for the note. I thought about it and at least she went to him and didn’t file a complaint. I have the luxury of interviewing the patient. She said she had felt misunderstood and like he had misinterpreted what she said. I think she thought she would be understood by doing this.

I find it weird that the notes would be removed from viewing. Don’t question a psychiatrist? She is harmless. I just think it’s weird.

 

[WisNeuro]

It's not weird, just illegal.

 

[PsyDr]

Sounds like someone I would NEVER use the term “client” with, and a patient I wouldn’t treat.

My notes are my professional opinions. So long as I am liable for the contents of the notes, they are not a group project.

 

[WisNeuro]

Patients are welcome to disagree with things, and providers can always wrote an addendum with that info. But, you cannot delete or alter notes.

 

[psych.meout]

 

[R. Matey]

I'm a bit confused. It sounds like the notes still exist, but you just can't view them?

 

[psychma]

I'm a bit confused. It sounds like the notes still exist, but you just can't view them?

The notes still exist but when I requested they didn’t come with. I had to call and psychiatry told me where to request them. I have still not received them after 3 weeks

 

[psychma]

Sounds like someone I would NEVER use the term “client” with, and a patient I wouldn’t treat.

My notes are my professional opinions. So long as I am liable for the contents of the notes, they are not a group project.

I tend to agree with that. My sense is she was looking to explain herself. Still, even if I was offended or found it offensive in some way, I can’t see removing my notes from the record.

 

[WisNeuro]

The notes still exist but when I requested they didn’t come with. I had to call and psychiatry told me where to request them. I have still not received them after 3 weeks

Ok, so they were not deleted, which would be illegal, they just were not sent. When this happens, I simply send a message with my state's relevant statute on timelines for sending requested healthcare data, along with the first date I requested the data, along with a deadline after which I will make a formal compliant to the authorities. Has never failed to get the job done.

 

[R. Matey]

The notes still exist but when I requested they didn’t come with. I had to call and psychiatry told me where to request them. I have still not received them after 3 weeks

Ok, the thread title is a bit misleading

 

[psychma]

Ok, the thread title is a bit misleading

I still haven’t gotten them. Who knows?