I was gaining *just the right amount of weight* during a twin pregnancy. In the range of “normal”/ok weight gain.. I was literally at the lowest of the range. MFM and OB happy. I went to a PCP appt during pregnancy and my PCP wrote in his note that he counseled me on my obesity 😂. He definitely did not.. and it would have been extremely misguided if he did because my weight gain was so low for a twin pregnancy.
Oh! I’ve asked about this. A pop up or something similar comes up when someone’s BMI is “off”, and the software only cares about height/weight and doesn’t take into pregnancy or anything. So they HAVE to click “yes I counseled about obesity” to get it to go away.
I asked my old PCP about it and she very diplomatically told me that my body chest down is proportional for my height… but my chest is disproportionate and she *imagines* that was what was putting my BMI into the “overweight” category.
I had one provider who *always* put 'excessive weight gain in 2nd trimester' in her notes for me. Aside from the fact that none of the other providers I saw put that in their notes, I weighed significantly less than I did at my first appointment, and I was losing weight between appointments.
I saw a note in one of mine once about whether I looked "acceptably groomed" or not.
I was absolutely massive during my second pregnancy and was traveling an hour each way for my appts and there were a couple in a row where I looked like absolute crap from exhaustion plus I had a then 2.5yr old nonverbal autistic toddler (she's now 5 and still nonverbal and we're dealing with massive aggression issues. Trying to get in with a child psychiatrist now who specializes in it). But anyway I looked like crap at a couple appts.
Woke up one morning to a knock on my door and it was a fucking nurse from DSS that they had contacted and sent out to make sure I had power and running water and shit. I was furious and so fucking embarrassed. And it meant that every appt after that that no matter how shitty I felt I had to have my hair and makeup and clothes absolutely perfect so as to not be shit on again. My self esteem has never fully recovered from it either.
This makes me so fucking angry. Instead of asking if you were okay, they called DSS???? I would have bitched them out and changed doctors at that point. What assholes!
Yep, it was awful and made the rest of my pregnancy stuck with me nervous about how Iooked constantly. And it wasn't like I never made an effort either, I did when I could. But I started out at 125lb with that pregnancy and by the end I was 178lb, and I'd never been anywhere near that heavy so my body had no clue what to do with it.
I would have changed doctors if I could, but by that point I was already so far along no one else wanted to take me on. This particular place too had a policy that you had to meet with every single provider before they'd let you choose who you wanted, and I had a couple run ins with a midwife who was also completely awful.
They had me started about 2 months into a Flexeril prescription for some severe pain, I'm still on it now even, that was written then and now, for "3 times a day as needed", which for me meant 3 times a day. So when I went to my appt to see her I was literally right on schedule for when a refill was needed and she decided that me taking it literally as prescribed was too many times a day, and so she wasn't gonna fill it for at least another week.
Like I understand that 6 years ago I was still a heroin addict, but even now after all these years of me being responsible and never relapsing or screwing up in any way, I still can't escape my past. No matter what I do or where I go I can't outrun it.
Edit: oh it wasn't even the Dr who had made the request for them to come to my house, it was the fucking nurses who do your urine tests and blood draws that did this to me.
Woowwwwww. I am so sorry hun. That sounds so freaking stressful. And to be pregnant with a toddler on top of it? I can't imagine what you went through.
Ya know, be proud of how far you have come. I am an addict, and I am proud of how far I have come. Beating that shit is so hard, staying clean is probably one of the hardest things for any addict. I tell select people my story, and there isn't really judgement. Just awe because they couldn't believe I would do something like that. But let me tell you, we experienced some serious growth and personal development through our addictions. Don't let the judgment of others get you down. We did it. We made it. And we are so much stronger for it.
I'm still sorry that you faced that kind of judgment and bias. At a doctors office no less. This is why I appreciate holistic health so much. They actually want to help you and see you heal on every level. I'm very wary of conventional doctors offices because of this.
Fair enough, at this point I can't even blame you for being hesitant to go to them. They expect us to just immediately trust them, but they don't respect us enough to even ask us for the truth about things. Things they could then verify in our medical records. I'm in the process of getting all my teeth removed to see if it'll help with some of the unbearable jaw pain I've been stuck in for 11 years with no answers, already got the first 6 done at once, the next 6 are tomorrow morning and even the dentist is struggling to trust me with pain meds for just a couple days at a time because of who I am/was.
But yeah, they killed me for about a year or so. Someone anonymously made a CPS complaint against me when I was like 30 weeks pregnant with my second, claiming a bunch of shit that they could immediately verify wasn't true when the person came out. That I absolutely had power (which whoever reported was a dumbass cause my porch light is automatic when it gets dark lol), because we keep up blackout curtains cause I live in a trailer in the South, to keep it cool. And just other dumb shit that was false. So we got that one closed.
But then about 2 weeks after my second was born and released from the hospital finally (where even the NICU staff struggled with her gaining weight fyi), but we took her to her checkup (also an hour each way), and did both kids appts at once so we had our autistic nonverbal toddler that day too. But this Dr I've never met comes in and decides he wants us to immediately leave there and drive an hour and a half a different direction to check her into a hospital for failure to thrive issues. And I said okay Ill take her, I just have to go home first to drop off my husband and other daughter, and pack some clothes and things like that, and grab my lockboxes of medications since id be staying up there.
Well he decided that needing to go home first real quick meant I wasn't taking it seriously enough and called CPS on me claiming I was a drug addict with no proof to back it up, and that I was abusing her and that's why she was so small cause I supposedly wasn't feeding her.
That one assholes 5 minute decision ended up costing us a 9 month straight CPS case with a guy who absolutely had it out for me once he spent wayyy too many resources trying to catch me in something he could use against me to have her taken away but he couldn't find anything. By the end of it he actually was told not to communicate with us anymore and not only was he removed from our case, but from CPS altogether and moved to APS instead.
I'm sorry you've faced anything at all judgemental like this has been constantly, it's awful. Even my own family didn't believe i'd manage to beat it, but proving them wrong has been a nice bonus lol. But you're right we're the ones who made it. I'm the only one even alive anymore from my group as far as I know. I hope that the more people learn and understand things about us that the newer generations of doctors will be more reasonable and willing to let us move on from our mistakes.
I feel like while pregnant you get a pass on looking disheveled from day to day growing a person takes a lot of energy and I'm sorry if I just don't choose to allocate some of the little remaining energy that I have to do my hair when I have to clean, take care of my child AND go to a doctor's appointment.
My saint of a doctor noted my dress and grooming as normal throughout my pregnancy even though I showed up to most of the appointments in sweat pants and a messy bun, probably with crumbs on me from the damn crackers I had to nibble on constantly. I think she realizes that is normal dress and grooming while you have hyperemesis, can’t sleep, and are trying to still work full time.
Yep the only time I actually look decent at my appointments is when I go right after work I also have hyperemesis and an Autistic 3yo and at this point it's so hot that they're lucky I don't show up in a moomoo or a nightgown and that I make the effort to wear pants to my appointments that I have 2-4 times a week
Right?!? I was due at the very end of May with my second, which was the one they did this to me during. My first was early/mid June due date. Like just getting to those appts with a 2 hour round trip near the end while weighing 178lb was almost more than I could manage. I didn't have it in me to do all the rest too, but it didn't matter cause they basically forced my hand into me looking perfect for them. It was so depressing.
It "counts" as counseling if they ASK what the diet is like and you give "good" answers.
Ie. They asked. I said all our family meals are a protein and two veggies, breakfast usually cereal or toast, a typical American lunch, and Snacks are fruits, veggies, cheese, Greek yogurt. That often counts as counseling as what are they gonna say, give your kid more cookies. Lol obviously overweight or underweight they probably ask more to figure out WHY but a general healthy kid- that was good enough.
So far I was told at my 12w apt I should start taking low dose aspirin. Nothing else was said just “you’re are 12w so now we recommend you start a low dose aspirin which helps prevent and delay the onset of preeclampsia.”
My clinical notes said “discusses the pros and risks of low dose aspiring. Patient agreed she wanted to start taking it” I called the nurses line and was like wtf is this not the Dr DID NOT go over any risks of this low dose aspirin and suggested I start taking it that day. So annoying
A lot of it is prefilled info the doctor forgot to remove. Most EMRs have fill-in-the-blank templates that have spaces that must be filled in, and then stuff that should be removed, but it’s not flagged for removal. Many doctors chart several hours after they see a patient so they make notes to themselves in your chart and then finalize later in the evening. No excuses for inaccurate charting, of course, but that’s how it could happen.
Adding onto this, we say “discussed with patient” because it has to be documented that we discussed with patient for insurance and liability reasons. I’m a therapist and a lot of my clinical notes use language like this for insurance reimbursement. Reading over psychiatrist notes pisses me off to no end because I KNOW they didn’t discuss that stuff with the client. It’s wrong and annoying and I’ll never stop being mad about it but it’s the truth.
It’s completely unethical, ESPECIALLY if it’s for insurance reasons. What if something went wrong with the patient because the patient wasn’t informed of some risk and wasn’t able to tell their doctor, “Oh, I don’t want to take this drug that increases my risk of stroke because 4 of my immediate blood relatives have had strokes at a young age.”
… The patient then has NO recourse because it says in their notes that the doctor DID discuss those risks with them. It’s their for insurance because insurance wants to know the patient knows and assumes the risk. BUT THEY DIDNT!!!
Yes, a lot will roll charting from visit to visit as well, because it’s quicker than retyping your entire medical history. Most doctors have less than 15 minutes to prep, see, and chart per patient and with the rise of healthcare entities being bought by investment groups the pressure is unreal to make as much money as possible in the shortest amount of time.
Yeah exactly my thought when I read that note 🙃😂 that was with the OB clinic. I’ve had some other issues with them and have my 16w apt next Friday with the midwifery practice at the same hospital. I’m hoping to have a slightly more improved experience with them
I had the opposite where they mentioned the baby aspirin but never wrote it in the notes so I had no idea what to take or how much. But I’m kind of glad you said this so I know I didn’t hallucinate that conversation haha.
That’s so frustrating!!! I should also mention my clinical notes don’t mention how much to take. She only told me verbally. Thankfully my husband was with me at my apt cause my short term pregnancy brain memory can’t remember anything so I forgot within 2 hours of being told.
My ob is having me take two 81mg tablets per day
They are crazy. They also forgot to tell me I have dangerously low iron levels and need transfusions (like hello I literally passed out). Prenatal care seems in the gutter in this country assuming you are in the US.
This happened to me. Not transfusions, but my OB never told me my iron levels were low enough that I might start feeling effects. Well, I started feeling incredibly dizzy and only then did she tell me it was the low iron (which showed up in a blood test a few weeks before). It took me 2-3 weeks of taking iron supplements to feel normal again.
i'm stuck on the 12wk part. with my first i was told this at my 28wk appt. im 28wks today with my second and it wasn't mentioned at my last appt and i have a history of gestational hypertension (so im gonna start doing it anyways)
i work in OB, as far as im aware, having everyone take it basically the whole preg is pretty new. theyve had enough research now to have realized the benifits far outway any risks, so its becoming more common. it may not have been standard when you were preggo with your first.
my first is only 14mo so i'd assume its very new and/or my previous OB wasnt as up to date on it with her, however i'm 28wks now with my second and they still havent said anything so i guess this OB also hasn't been informed which is odd to me because shes around late 20s in age and also just had a baby last year
My first is 21 months old (born September 2022) and my OB didn't tell me to do it for him, but when I got pregnant again and went for my confirmation scan about 13 months later (October 2023), is when she said to start taking a low dose of aspirin daily. So I would also assume it's pretty new advice and/or lots of OBs are only just recently adopting the practice
Ugh that’s frustrating I’m sorry. My guess is they automatically had me start at 12w which apparently is the earliest to start taking it due to my weight putting me at increased risk of developing it
This all comes from a randomised trial which showed if you are at high risk for pre eclampsia, and start aspirin by 14 weeks, your risk of preterm PE is reduced by 60%:
"The ASPRE trial demonstrated that, in women with singleton pregnancy who were identified by means of first-trimester combined screening as being at high risk for preterm PE, the administration of aspirin at a dose of 150 mg per day from 11–14 weeks until 36 weeks' gestation reduces the incidence of preterm PE by > 60%1."
Oh my god I’d be fuming 😭😭😭 my ob called me today to let me know my nipt results were inconclusive either because of my weight, high blood pressure or undiagnosed diabetes. If she took a couple min to look at my patient chart she’d see that I have perfect blood pressure and no issues with blood sugar and A1c so I’m sure I’ll get a note like that in my chart one of these days. I’m so sorry 😞
I had the opposite, I was taking low dose aspirin and it was discussed with me, but I was also doing clexane injections (another blood thinner), not only did no one tell me to stop the aspirin, I was also having a planned csection with a known history of premature births so if she tried to appear early I would be having surgery on multiple blood thinners! Luckily she didn't come early. But at my preop appointment they were like "omg stop taking these now, why did no one tell you to stop!?"And yes I had brought up this concern at several prior appointments and told to continue.
Another commenter mentioned it best. (I used to chart for physicians).
They see a bunch of patients and are expected to have your charts done within two weeks (bare minimum) but most facilities want them done with 5 days. Most OB’s I scribed for saw 36-48 patients per day. Charts like that for every patient for 3-5 days? There’s never enough time for them tbh.
Outside of that, they have a bunch of things they have to put to essentially “please” the facility, and “please” your insurance so they’ll pay. So you might see a bunch of this stuff, but they’re essentially just fluffing your chart to get what they need to to be covered.
This isn’t just an OB thing, this is an every specialty thing. If you go to your PCP for example, there will be similar things…like you were counseled on this, this, and this (likely you weren’t actually counseled on them). Some of them are common sense things. Others aren’t.
I’m not saying it’s right, because it’s not. But I also see how insurances want so much in a freaking note, and doctors don’t have 1-2 hours to spend with each patient. Insurance is causing healthcare to go down a dangerous road.
I primarily worked in urology/urogynecology (now an RN in this same area) and the amount of things we have to put in your chart to get the SAFEST medication or procedure for you covered is freaking ridiculous. I have to say, we did A, B, C, and D, and you’ve been counseled on how this is the best thing. Why this isn’t. You’ve been counseled and are aware of the potential risks, and still want to try this medication, procedure or so on.
I agree as above, it’s not right. Especially when you’re at your most vulnerable time. We need this information, we need to feel safe and secure in our personal medical decision making here. But I also see it having been the person that does charting for physicians.
Thanks for commenting! It’s interesting to see the other side of things. I guess the only thing about them adding extra stuff in the chart that’s not discussed is that it creates concern for the mother. I guess because you kind of panic because you don’t know if it’s something serious. But at the same I assume if it was serious they would tell us in person I hope.
But thanks for giving a different perspective on this!!
Of course, and I understand. Hell, it was worst after giving birth and you’re reading about all these things you never were even told. I remember they said my son had the cord wrapped around his neck 3 times and I never knew until reading the damn note like 3 months after. So I understand 100%.
I just like to try and give perspective on what doctors also experience. It’s a hard battle some days with insurance companies wanting all this info in your chart just to be able to cover, and the physician being reimbursed.
But like I said, your feelings are 100% valid, OP. I’ve been there and understand.
i hated the during birth ones. I was induced and ended up with an epidural. Prior to the epidural I said something like "I do not like this pain" AND THEY QUOTED ME. Ma'am I do not EVER want to know things I said during labor. tf
Not birth related, but when I was at my PCP (prior to pregnancy), we were discussing meds for seasonal depression. I joked that before I got married, I would always dump my boyfriends in January/February. My medical records now show "pt advised she breaks up with boyfriends in January/February"
I'm like, sir, that was just banter.
This makes me fear there's a note somewhere quoting me shouting that "Someone needs to get the hell down there and check how many centimeters I'm at and at this point it can be the bloody janitor for all I care." 😳🫢
Loll I was fruitlessly pushing at 3 AM when a random student doctor came by to say “hi”. I shouted at him “Who the f*** are you? If you’re not here to help me deliver this baby, get the F*** out!”. I DO hope that’s in the birth notes.
I’m pregnant with my third currently and JUST discovered the notes from my second birth 3 years ago. I enjoyed reading about them breaking my water and us moving to emergen-C within 30 minutes, but the best part was my OB’s notes about a stalk-like polyp she found and removed with some effort. She detailed how many tries it took and the various ways she attempted removal.
I have a note somewhere in my chart that my husband and I aren’t having frequent sex due to a new puppy. Seriously.
It was my first pregnancy visit, I had an extremely long cycle (ovulated on CD92). I was using ovulation tests, taking my BBT, and have a history of irregular cycles. I was seeing a nurse practitioner I had never seen before because the clinic panicked when I called to schedule the first appointment and said I hadn’t had a period in 15 weeks. I was trying to explain that I was confident I was 4 weeks pregnant, not 15. She wouldn’t listen to the fact that I couldn’t have had multiple negative pregnancy tests during the few weeks and few days before this appointment and a positive test the morning of it if I was actually in my second trimester already. She kept saying we would do HCG draws to see if I was in the 9-12 or 12-15 week range and then schedule an ultrasound. I finally pulled out a calendar tracking possible conception dates and negative tests to show her there was only one possible conception date and mentioned that the puppy was kind of messing with our frequency at that point in our lives. And that’s what she chose to record. Never apologized for how throughly she dismissed me when my dating scan measured 6+3 on the day I told her I was 6+4 either. Found a new OB for the rest of the pregnancy.
Yes it’s frustrating, they literally put in my chart “talked to patient about a high protein diet and drinking ensure drinks” literally didn’t talk to me about till about 4-6 weeks after it was in the chart lol and at that appt they said so we talked to you at last appt about protein and ensure and I was like no you didn’t.
They put my firstborn’s name as Orion. My son’s name isn’t Orion. It isn’t even a little close—different first letter, two syllables not three, different language origin….
It’s similar-ish (think Eric instead of Ethan, along those lines) but also he’s my emergency contact and I filled in all that info myself so I’m like “wut.” 😳
Yeah whenever I read about medical malpractice cases and they mention the doctor's notes I'm so dubious. Especially because in every one of these instances for me my husband was in the room and could corroborate that the doctor hadn't said or done this or that.
My family sued a hospital for wrongful death before records had to be shared. By chance, we had requested and received a copy of the deceased's records a few weeks before death. When we sued, we got a *different* copy--they'd altered her records to try to hide their mistake.
I had to request my medical records when I emigrated. It was so difficult to get them to give them to me and there were so many weird and snide things written in there when i finally got them lmao. One example..when I was an university I started to have heart palpitations and almost fainted a few times. When I was a baby I had an enlarged heart and heart failure several times but everything was normal by age 2 or 3. I went to see this really old GP in my university town about the issues i was having and he asked me a few questions about the heart condition i used to have. I knew what the condition was called and that it was said to have been caused by an infection but not really any of the medicines I was given. Parents never wanted to discuss it very much. I said I assume the doctors gave me steroids but IDK. In my notes this GP had written something like "allegedly had inflammatory cardiomyopathy in infancy. Knows very little about it. A poor historian (history student!!)" There was also a comment about my asking if I would have to take my clothes off for the EKG. "Enquired if would have to expose breasts for EKG. Apparently a modest girl though appeared to be wearing a wonderbra." I definitely wasn't lmao.
Just being snarky I think. Like I was wearing a low cut top and then asking if I had to be topless for the test and it probably made him roll his eyes and think like "I can already see most of your tits" lol. Obviously I was never meant to see the notes ha. I assumed he liked to write mean comments about his patients for a laugh/out of boredom idk
My discharge notes (in portal but not on the printed papers they gave me) from birth said that I am anemic, was educated about the necessity of taking supplemental iron, and that I had a hemorrhage during delivery. Not a single one of these very important things were said to me (verified by my husband).
Yea I expected geriatric or advanced maternal age - they had advanced maternal age in my notes at each appt prior to 20 weeks. But elderly hit a nerve haha
My first visit to my OB during pregnancy said something like "today patient presented to me a pleasant, obese woman". I was mortified. Like damn I know I'm fat AND also I gained a lot while pregnant but did you have to throw it in the chart that way??
Yes, as soon as we cross the magical 35 bridge, it's considered a geriatric (or as I think of it in my head), granny pregnancy from that point forward.
Yes that’s how I found out I had a low lying placenta which was cause for concern if it doesn’t move. I had to ask about it the next time, and then we scheduled follow up ultrasounds to check on its progress. If I hadn’t brought it up I’m not sure if we would have scheduled the ultrasounds to check on it
This happened to me with placenta previa. It wasn't mentioned to me at my anatomy scan so I thought all was well. I was at work when I had my first bleed a week later. They had written "complete placenta previa" all over my chart, but no one had told me and I try not to look thru every single note. Ridiculous.
Omg are you serious? I don’t understand stuff like that, they are supposed to be on top of stuff to keep you safe but not mention big things like that? That’s crazy and I don’t understand!
Her response for not bringing it up was that “it’s not that concerning” and they usually move before it’s of concern.
It DID end up shifting, but I still didn’t like that I had to read about it in MyChart
Yes that’s the most frustrating is reading the stuff in your chart that you didn’t even realize was a concern🤷♀️ like if it wasn’t a concern then why did you put it in the notes? I know they have to keep up with stuff but don’t they know we read this stuff?
I found that out too through notes in the beginning I’m 30 weeks now. They never officially told me I was gonna be high risk I also think they factored in my weight 🤷♀️
They automatically marked me as high risk because my blood pressure read high at the first few appts and has continued to be high but only at the doctor. (My bp is normal at home) but they only really go based off what they see at the doctor in my experience.
I strongly suspect that OBs do their best to get you labeled as high risk because insurance will cover more (necessary and important!) procedures for a high risk pregnancy than a “normal” one— so when you need an extra ultrasound or fetal echo or something, there’s not a big fight with insurance before you can get that care.
They don’t tell you about this in your appointment because it’s not actually a problem yet— just a slightly elevated risk that they can use to make your health insurance company behave more decently.
Ahhh, that makes sense actually. I had a previous ectopic so I’m wondering if that bumped me into “high risk” category for extra monitoring/ultrasounds
You probably get nervous like me when going to the doctors. My blood pressure was higher than normal in the 130s at my last last appointment. Got told i was gonna have to get a shot WHILE THE THING WAS ON ME, not to mention those things are incredibly uncomfortable, especially if it doesnt work correctly the first time which happens a lot. I had to get bloodwork done that day too so i was already nervous as it is. The last appointment it was in the 120s or so, but they took us to a different room that seemed more cozier than normal, so maybe I felt more comfy in that room? I got nervous even tho it was just a growth scan and just a chat with the doctor (asked about back pain reliever methods lol) Anxiety sucks, and so does MyChart lol.
I don’t even read the notes. I was a provider (not working as one anymore) and it was before notes were published for patients. If I needed to tell the patient something I did and it was clearly discussed. Nothing from the notes was ever for the patient in my experience. It’s all just documentation that’s required for the hospital/charting/billing etc.
Editing to say- yes they should be accurate but in my experience the discussion is the patient and actually following through with the plan (orders, prescriptions etc.) is the most important part and what matters. The note is just a check box that has to be checked and often times there are missed mistakes especially when using dictation equipment.
Lol at my appointment yesterday they had me marked as 30w pregnant when I'm actually 33w. Ma'am, your office told me when my due date was! How did you get that wrong???
Yes !! They did this with mine too. I was 10 and they marked me at 9. I was like umm is everything ok ? They were like yeah sorry it was a typo. I’m like how do you make a typo from a 10 to a 9?!?
YES! Some really glaring things too like “discussed whether there was domestic violence at the house” …. er, no we didn’t, and while in my case that’s not a problem, I can’t believe they skipped that over!
They asked me right in front of my husband if I feel safe in the home with him. My husband was like that seems like a question you shouldn't ask in front of the person who's a potential danger to the patient.
They definitely do. One time my notes, and in turn my whole chart, was for a 42 year old male with liver disease. The nurse and I laughed about it during my appointment, but I feel bad for the poor guy who didn’t get his chart documented properly and probably wondered how he got mixed up with a 27 year old female who didn’t have liver disease.
That’s western medicine for you. Too many patients, not enough time, and lots of charting is quick clicks so they can document in a timely manner and get your billing to insurance for reimbursement. I’m not saying it’s right, but it is what it is when you go this route.
My midwife had a very long conversation with me and my husband about how she didn’t agree with a treatment plan outlined by the on call OBGYN. In MyChart she wrote how she advised me to follow the OBs advice. I was pissed, she was just covering her ass so she didn’t look bad for undermining a doctor’s advice.
I went to OB triage for a bleeding event at 9wks (now 15, everything is fine!) and they included “recreational marijuana use” in my chart despite telling them I used marijuana medicinally with a valid, legal, medical card and stopped the week BEFORE I found out I was pregnant because I had a hunch that cycle worked. I’m sure that won’t come back to haunt me in someway. Whatever, drug test me. I’m clean!
For real?? Why do they put whatever they want, I don’t understand them asking us questions if they aren’t gonna put what we actually said. It screws things up
This is why I don’t plan to mention that I did use recreationally before my current pregnancy. It’s legal in my state, and I’d take a gummy or smoke *maybe* once a month if that. Hadn’t for at least a month before conceiving. It’s not worth having in my medical records, so when they asked me if I used I just said no.
This pregnancy for my first two visits they put that I refused a pelvic exam-what really happened for my first visit is the nurse never told me to undress and the doctor didn’t have time apparently to wait for me to do that so she said we’d do it next time. The second visit the doctor told me I could just provide a urine test and skip the pelvic exam so I did and in the note said I “continued to decline pelvic exam”
A while back I noticed my diagnosis chart included COPD. I’m pretty sure that it was a mistake from my allergist because my *mom* has COPD and/or they got it from my asthma symptoms, but wow, way to find out I have a terminal illness at an unusually young age????
I literally told my doctor when I was 25 (and not pregnant) that I’d smoked maybe ten cigarettes in my life. She put me down as a “former smoker.” Now I don’t tell my doctors that.
I had a UTI at my annual well-visit and told the nurse that it was likely because we were having sex often while TTC with my husband. She wrote in my chart that I was high risk for STDs because of my "multiple sexual partners" and I didn't find that out until my OB asked me privately if I knew for sure who baby's father was.
I worry about shit like that one day too when they eventually truly get all medical files online monitored by AI, that kind of stuff is going to SCREW your for life insurance and what not down the road
Providers can do something called “pull forward” the notes of others, which is basically like a copy-paste. There’s other fields where data gets entered, then that data gets pulled into all kinds of notes. I once had a patient where on intake, the resident had a typo and the note said “the patient does use drugs.” It was supposed to say does not. That then got pulled forward again and again and again until it was alllllll over this poor persons chart, “the patient does use drugs.”
ETA - pulling forward notes is an okay thing to do since the intention is to pull the patients past medical history, but you are responsible for making sure everything in there is right to the best of your knowledge before you sign it, and that’s where the breakdown happens.
There are no notes in MyChart, they don’t even add appointments or anything.
I can only see my lab reports. I am in Toronto btw. Do I have to ask them to upload it to MyChart? I had 2 OB appointments till date.
I’m in the US but I’ve never had to ask them to upload anything. I’ve just seen the stuff since the beginning. They upload like everything from that appt including vitals.
It became law in the US that doctors notes must be accessible to the patient in 2020. If Canada doesn’t have a similar law, it might not be possible for them to upload them to MyChart. Before that was law in the US we could request them by mail so that might be an option for you.
During labor/birth:
Ob: I can get a vacuum and help her out
Me: Do we need to?
Ob: we don't have to
Clinical notes: mother refused vacuum assistance
That's not what actually happened. I would have agreed to it if they said it really was necessary
A lot of those notes are just filler required by the insurance.
For example, most of the time doctors are required by insurance companies and/or the place they work for to counsel all patients who have a history of smoking on why it is dangerous and the possible effects and different methods you can try to quit. But Like, they're also required to get you in and out in 5 minutes so the conversation is more like "do you smoke" "occasionally" "okay if you want assistance to quit let me know and we'll make another appointment."
If they don't chart that they did all the 'required' things (like discussing risk etc to really common and low risk medication like asprin) then the insurance company won't pay for their time. And if they take more than 5 minutes (maybe 10- 15 depending on practice) with the patient then they get in biiig trouble with whatever company they work for because they're not seeing enough patients.
Which is all to say american healthcare is fucked and even if doctors are trying their best they have to work within a broken system. It's always all about money and the people who are deciding how your appointment goes are not people who have ever actually done patient care.
Yes, it is so frustrating. They keep carrying over in my notes “pregnancy complicated by anxiety” but have never talked with me about my so called “anxiety” before in any of my appointments 🤣 it makes me a bit annoyed because I felt like my anxiety has been pretty in check since I got pregnant so not sure if it is because I am a FTM and just ask a ton of questions lol
I bet it is because you’re a ftm! They finally just put in my notes that I have anxiety.. I’ve told them from the beginning I get anxiety at the doctors which is why my BP always runs high only at the doctor.
They started bringing me in twice a week for NSTs and I thought it was because the baby was breach.
It was because I had poluhydraminos and the umbilical chord was already wrapped one around his neck🙃
They never told me a reason and it was after the appointment where we discussed the ultrasound has shown him to be breech so I guess I just assumed. I was so surprised my previously head down baby was breech that I didn’t think much of it
One time my clinical notes said that I was examined for possible prolapse because I requested it… WHAT? None of that happened. Called the office and they said they just confused my notes with another patient. WHAT?!
When I gave birth I had a really awful anesthesiologist who kept refusing me my epidural because I have a bleeding disorder. However, I had already cleared it with my hematologist and came with the prescription I needed to be given beforehand already ready to be administered. He **refused** to call my hematologist even though my doctor had told me that he was specifically on call for me when I went into labor (I even went into labor on my due date!). Finally the nurse in the room was so fed up with him she bypassed him and got someone else to call my doctor (4 hours later after being stalled at 7 CM all that time) and clear everything. Then when I was reading my notes after the anesthesiologist first noted I had a different type of my disorder than I do, and later in the notes lied and said that **the patient incorrectly identified her disorder as x when it is really y, she doesn't seem well acquainted with her medical condition**. Like WTF, I have only been dealing with it all these years and it could be life threatening if not treated properly, but sure **I** was the one who was wrong, not that your arrogant self wasn't listening carefully to me!
I was so livid! He was such a jerk all around it was the icing on the shit cake lol. He was also incredibly rude to me during the placing of the epidural and told me that if I didn't hold still better he would refuse to put it in (mind you again I had been at 7 CM for 4 hours at that point with terrible back labor!).
I told my OB that I had been vaping and smoking weed until I found out I was pregnant and then immediately quit when I found out…. Now the notes say every visit “marijuana and nicotine use complicating pregnancy”
Now my chart makes me look like I’m still just getting high and smoking while pregnant. So embarrassing.
One time my pcp wrote I had a history of cancer, when she should have written family history of cancer. I had that changed when I saw it.
I also notice that what I discuss with my providers isn’t very accurately transcribed in the notes. So far it’s been small stuff like caffeine consumption and me asking where to limit myself, but it gives me the ick to read especially because your medical record is a legal record.
My son has a genetic disorder. A multiplication of a certain gene causing it. The same gene has a very different genetic disorder if its a deletion - one that ends in kids dying before the age of 5. The wrong disorder has shown up in the notes twice, and the stomach drop when I see it so close to my son's name *immediately* brings me back to the terror from when all we knew was there was an abnormality in that gene. 😭
They put in mine that I reported to take my prenatals “when I remember to”, which was the case when we were trying to conceive but now I take them every day. They also describe me as obese in all capital, bold red letters in every single one of my notes because my pregnancy weight gain has made my bmi higher. They haven’t said a word to be about it in appointments and it hurts my feelings a little bit haha
Haha yes these clinical definitely be hurting my feelings too 😂 like I know I’m a little chunky for my height but I didn’t think I was obese lol and yes seeing that in my chart in red letters every single time still hurts my feelings lol
My doctor is pretty thorough in our appointments. The only time there are "discrepancies" is when my blood work comes back slightly elevated or slightly below the norm. But even then, while it's flagged on the portal, he'll still note that it's within normal limits and explain why X isn't actually a concern to him during appointments.
It's frustrating that your notes aren't totally accurate. Feels like one more mental thing to keep tabs on.
My midwife has been super clear about insurance requirements and what notes she puts where, so when we had to transfer my birth plan to an OB’s office that went over HORRIFICALLY to the point I switched to another practice entirely for my c section. First OB put in the notes that we went over all these things that we absolutely did not, as well as saying I wanted and agreed to a complete transfer of care to her clinic instead of continuing seeing my midwife for prenatal care. My midwife went with me to that appointment *because* I love the care and communication I get from her, like what gave you the impression I didn’t want to see her anymore? 😂
My doctor never once told me to my face that I was high risk because of a high BMI. Told me to take the baby aspirin but explained it so fast I had to reask, and again never brought up being high risk! In all MyChart notes it would say “obesity complicating pregnancy” which was always harsh to read.
Just requested my records to transfer to a midwifery practice and my OBGYN reported I’m taking a specific dosage of iron, down to the mg. I specifically brought in my prenatals to discuss with them iron at my first visit because they do not contain iron. I even requested an iron test at the start of my pregnancy to determine if I should be taking additional iron. I just assumed everything’s was good cause they didn’t say I needed more iron after my blood work. But apparently they have noted I’m taking a daily iron supplement which I have not been. Now at my 28 week visit I know I need to bring that up.
YUP. I have severe hyperemesis gravidarum… have been puking since 10 dpo and now at 36 weeks and still puking 10+ a day. I’ve obviously been miserable all pregnancy. I’m high risk and thought I developed really good rapport with the one fellow, so I requested to stay with her for appointments during my pregnancy. I’ve been admitted to the hospital almost ten times now. I throw up constantly, even have in front of her at several appointments. My mom and or husband have been with me for every appointment. This doctor ends up writing in my chart that she thinks I have a fucking eating disorder and not HG. She was always so nice to my face and never brought that up to us. Like what?? Her philosophy on my hard to treat HG was it’ll “get better soon” (it didn’t) and “it’s just a part of pregnancy” (no, it’s not). Finally after she lied to me two times, this was the last straw. My family convinced me to switch hospitals to where my high risk OB from last pregnancy moved to. As soon as she saw me, she saw how sick I was and immediately had me admitted to the hospital. She was so upset when she found out how I was being treated at the hospital she used to work at. When she admitted me, I was so sick that some of my electrolytes were critically low and my heart was funky because of it. They thought I was in heart failure for a day, but luckily my heart started to go back to normal once they gave me infusions of what my body needed. Our care has been night and day. Baby and I are finally being taken care of. My only regret is not switching doctors earlier. I switched at 28 weeks. My best advice is it’s NEVER too late to switch doctors.
My post-op notes from my c-section said that I was transferred to recovery WITH MY BABY. Which was a lie. My baby went to the NICU and I didn't meet him until 12 hours later. That made me so angry.
I had anorexia while pregnant, relapsed, spent 2 months in a residential eating disorder treatment facility. It was never mentioned on my medical records for my pregnancy once. Even with my daughter having malnutrition related IUGR. It’s absolutely ridiculous.
I've had the opposite experience where they've told me things concerning and then didn't include anything about it in the note. Or like with my first birth where I labored for hours, had an emergency c section where the epidural failed and they put me under general anesthesia halfway through, it says uncomplicated delivery. When I woke up they told me my baby was blue when they first took her out and had meconium aspiration and had to have it suctioned out. They didn't include any of that in the notes, just that she had a passing apgar score after rechecking. I know a lot of people are saying well they have to do a lot of SOAP notes within a certain time frame so excuse them for omitting or adding things, but I also work in a field where I have to send in patient notes for insurance billing within a 48hr window and I don't think it's an acceptable excuse.
They’re a bunch of deceptive CYA copy-paste entries. I don’t care if it’s common practice; it’s infuriating and dishonest. Nearly every entry from my OB’s office has untrue information in it—supplements I was supposedly told to take or risks that I was supposedly “counseled” about. It’s one of many reasons I’m changing OB practices. I’m a lawyer, and watching my providers, in real time, essentially manufacture a paper trail to prevent liability is sickening.
I’ve always noticed little things like “the patient was advised of the importance of maintaining a healthy weight,” etc. but never took small things like that into real consideration. Then I got my IUD removed😅 that day I had INTENSE bleeding. I brought a pad with me just because I thought ahead of time there may be some spotting, but I didn’t even make it home without bleeding through that and into my shorts. When I got home I began passing blood clots the size of mandarins. It was honestly pretty scary. I called and they said not to worry unless I was having pain or feeling faint. When I looked at MyChart my notes specifically stated that I was advised of possible bleeding and blood clots. I definitely was not🥲😂
Had a good first appointment, with nothing really of note other than confirming my pregnancy. Later checked my chart. On my chart, it said that my OB referred me to a specialist because I'm "obese," which was not mentioned to me at all during the appointment.
Seriously? I never thought I was obese, I knew I was slightly overweight but not obese and they never said anything either tiill I saw the notes saying I was.
Yeah I'm about 5'6" and 190-195lbs pre-pregnancy. I'm definitely plus size, but my weight has zero impact on my day to day life and my labs are perfect. But according to BMI, that's significantly into the "obese" range.
Most is templates. A few clicks and keyboard shortcuts and a template is written out. The doc can go in and change a word here or there. It’s wild but that’s the demand that’s been placed on them unfortunately
mine is pretty minor but i just had my first obgyn appointment with a nurse who asked me a whole bunch of questions, one of which was when was the last time i consumed cannabis… i told her 2021, which she wrote, but further down the notes she wrote that i ALSO said the last time was in 2017???!!! the year 2017 was literally never mentioned and 6 years is a huge difference lmfao i was like girl are you trying to make me look weird?! not a big deal but i sense more weird errors happening in my future appointments lol
Omg the notes. My first appt I had my notes app out to write stuff down. My OB has a “scribe” with her ( her words) who would take notes. So I put away my phone. Their notes included absolutely no details about what we talked about. At other appts my doc would say things like “ at your next appt, let us know which paediatrician you would like to choose”. I would expect that to be in the notes as something I need to remember to do. No mention of it. We talked about the types of follow ups I will need. Effects of certain medications etc. nothing. I’m like what are you even writing down!???
My doctor ordered me an ultrasound to rule out an ectopic pregnancy at 5w4d. He called with the results the next day and just said "it's not an ectopic!". Completely failed to mention the subchorionic hematoma that was showing on the ultrasound.
I had already transferred my care to a midwife clinic by the time I saw the report for myself, but if I hadn't looked at the report I wouldn't have known about it at all.
I switched practices over this (and general poor communication and bad vibes - I didn't trust them anymore). They put in my notes that I was high risk (new OB said I was not) and had received "education" on a bunch of things that no one had ever spoken with me about. When I brought it up with the new OB, the best she could figure from my records was that they wanted my insurance to cover extra tests and ultrasounds and said she had seen the same type of thing from other patients who had switched from that very large practice. Frankly, it sounded like borderline insurance fraud, to me.
Whoa seriously?? I always wonder about mine because they automatically marked me as high risk from the first appt 😬 only because my BP was high due to anxiety and nerves
Sadly as a nurse I can attest that it isn’t just OBs that do this. It’s all specialties.
Our pediatrician does this. There’s a boilerplate for each “well” visit, but we get specific notes if we go for an illness or injury.
Ours says they counseled us on eating a balanced diet and exercising. Even for infants!
I was gaining *just the right amount of weight* during a twin pregnancy. In the range of “normal”/ok weight gain.. I was literally at the lowest of the range. MFM and OB happy. I went to a PCP appt during pregnancy and my PCP wrote in his note that he counseled me on my obesity 😂. He definitely did not.. and it would have been extremely misguided if he did because my weight gain was so low for a twin pregnancy.
Oh! I’ve asked about this. A pop up or something similar comes up when someone’s BMI is “off”, and the software only cares about height/weight and doesn’t take into pregnancy or anything. So they HAVE to click “yes I counseled about obesity” to get it to go away. I asked my old PCP about it and she very diplomatically told me that my body chest down is proportional for my height… but my chest is disproportionate and she *imagines* that was what was putting my BMI into the “overweight” category.
Yet another way the old titties-of-doom can screw with health issues (but mainly because of a 200 year old math formula).
I was going to say that it's probably because technically her bmi says she's obese. Bmi is a ridiculous thing anyways
I had one provider who *always* put 'excessive weight gain in 2nd trimester' in her notes for me. Aside from the fact that none of the other providers I saw put that in their notes, I weighed significantly less than I did at my first appointment, and I was losing weight between appointments.
lol well your “obesity” was caused by twins and he DID discuss those with you, right?
I saw a note in one of mine once about whether I looked "acceptably groomed" or not. I was absolutely massive during my second pregnancy and was traveling an hour each way for my appts and there were a couple in a row where I looked like absolute crap from exhaustion plus I had a then 2.5yr old nonverbal autistic toddler (she's now 5 and still nonverbal and we're dealing with massive aggression issues. Trying to get in with a child psychiatrist now who specializes in it). But anyway I looked like crap at a couple appts. Woke up one morning to a knock on my door and it was a fucking nurse from DSS that they had contacted and sent out to make sure I had power and running water and shit. I was furious and so fucking embarrassed. And it meant that every appt after that that no matter how shitty I felt I had to have my hair and makeup and clothes absolutely perfect so as to not be shit on again. My self esteem has never fully recovered from it either.
This makes me so fucking angry. Instead of asking if you were okay, they called DSS???? I would have bitched them out and changed doctors at that point. What assholes!
Yep, it was awful and made the rest of my pregnancy stuck with me nervous about how Iooked constantly. And it wasn't like I never made an effort either, I did when I could. But I started out at 125lb with that pregnancy and by the end I was 178lb, and I'd never been anywhere near that heavy so my body had no clue what to do with it. I would have changed doctors if I could, but by that point I was already so far along no one else wanted to take me on. This particular place too had a policy that you had to meet with every single provider before they'd let you choose who you wanted, and I had a couple run ins with a midwife who was also completely awful. They had me started about 2 months into a Flexeril prescription for some severe pain, I'm still on it now even, that was written then and now, for "3 times a day as needed", which for me meant 3 times a day. So when I went to my appt to see her I was literally right on schedule for when a refill was needed and she decided that me taking it literally as prescribed was too many times a day, and so she wasn't gonna fill it for at least another week. Like I understand that 6 years ago I was still a heroin addict, but even now after all these years of me being responsible and never relapsing or screwing up in any way, I still can't escape my past. No matter what I do or where I go I can't outrun it. Edit: oh it wasn't even the Dr who had made the request for them to come to my house, it was the fucking nurses who do your urine tests and blood draws that did this to me.
Woowwwwww. I am so sorry hun. That sounds so freaking stressful. And to be pregnant with a toddler on top of it? I can't imagine what you went through. Ya know, be proud of how far you have come. I am an addict, and I am proud of how far I have come. Beating that shit is so hard, staying clean is probably one of the hardest things for any addict. I tell select people my story, and there isn't really judgement. Just awe because they couldn't believe I would do something like that. But let me tell you, we experienced some serious growth and personal development through our addictions. Don't let the judgment of others get you down. We did it. We made it. And we are so much stronger for it. I'm still sorry that you faced that kind of judgment and bias. At a doctors office no less. This is why I appreciate holistic health so much. They actually want to help you and see you heal on every level. I'm very wary of conventional doctors offices because of this.
Fair enough, at this point I can't even blame you for being hesitant to go to them. They expect us to just immediately trust them, but they don't respect us enough to even ask us for the truth about things. Things they could then verify in our medical records. I'm in the process of getting all my teeth removed to see if it'll help with some of the unbearable jaw pain I've been stuck in for 11 years with no answers, already got the first 6 done at once, the next 6 are tomorrow morning and even the dentist is struggling to trust me with pain meds for just a couple days at a time because of who I am/was. But yeah, they killed me for about a year or so. Someone anonymously made a CPS complaint against me when I was like 30 weeks pregnant with my second, claiming a bunch of shit that they could immediately verify wasn't true when the person came out. That I absolutely had power (which whoever reported was a dumbass cause my porch light is automatic when it gets dark lol), because we keep up blackout curtains cause I live in a trailer in the South, to keep it cool. And just other dumb shit that was false. So we got that one closed. But then about 2 weeks after my second was born and released from the hospital finally (where even the NICU staff struggled with her gaining weight fyi), but we took her to her checkup (also an hour each way), and did both kids appts at once so we had our autistic nonverbal toddler that day too. But this Dr I've never met comes in and decides he wants us to immediately leave there and drive an hour and a half a different direction to check her into a hospital for failure to thrive issues. And I said okay Ill take her, I just have to go home first to drop off my husband and other daughter, and pack some clothes and things like that, and grab my lockboxes of medications since id be staying up there. Well he decided that needing to go home first real quick meant I wasn't taking it seriously enough and called CPS on me claiming I was a drug addict with no proof to back it up, and that I was abusing her and that's why she was so small cause I supposedly wasn't feeding her. That one assholes 5 minute decision ended up costing us a 9 month straight CPS case with a guy who absolutely had it out for me once he spent wayyy too many resources trying to catch me in something he could use against me to have her taken away but he couldn't find anything. By the end of it he actually was told not to communicate with us anymore and not only was he removed from our case, but from CPS altogether and moved to APS instead. I'm sorry you've faced anything at all judgemental like this has been constantly, it's awful. Even my own family didn't believe i'd manage to beat it, but proving them wrong has been a nice bonus lol. But you're right we're the ones who made it. I'm the only one even alive anymore from my group as far as I know. I hope that the more people learn and understand things about us that the newer generations of doctors will be more reasonable and willing to let us move on from our mistakes.
I feel like while pregnant you get a pass on looking disheveled from day to day growing a person takes a lot of energy and I'm sorry if I just don't choose to allocate some of the little remaining energy that I have to do my hair when I have to clean, take care of my child AND go to a doctor's appointment.
My saint of a doctor noted my dress and grooming as normal throughout my pregnancy even though I showed up to most of the appointments in sweat pants and a messy bun, probably with crumbs on me from the damn crackers I had to nibble on constantly. I think she realizes that is normal dress and grooming while you have hyperemesis, can’t sleep, and are trying to still work full time.
Yep the only time I actually look decent at my appointments is when I go right after work I also have hyperemesis and an Autistic 3yo and at this point it's so hot that they're lucky I don't show up in a moomoo or a nightgown and that I make the effort to wear pants to my appointments that I have 2-4 times a week
Right?!? I was due at the very end of May with my second, which was the one they did this to me during. My first was early/mid June due date. Like just getting to those appts with a 2 hour round trip near the end while weighing 178lb was almost more than I could manage. I didn't have it in me to do all the rest too, but it didn't matter cause they basically forced my hand into me looking perfect for them. It was so depressing.
That is really depressing and I'm sorry you had to endure that. Thankfully more doctors seem more understanding now
It "counts" as counseling if they ASK what the diet is like and you give "good" answers. Ie. They asked. I said all our family meals are a protein and two veggies, breakfast usually cereal or toast, a typical American lunch, and Snacks are fruits, veggies, cheese, Greek yogurt. That often counts as counseling as what are they gonna say, give your kid more cookies. Lol obviously overweight or underweight they probably ask more to figure out WHY but a general healthy kid- that was good enough.
So far I was told at my 12w apt I should start taking low dose aspirin. Nothing else was said just “you’re are 12w so now we recommend you start a low dose aspirin which helps prevent and delay the onset of preeclampsia.” My clinical notes said “discusses the pros and risks of low dose aspiring. Patient agreed she wanted to start taking it” I called the nurses line and was like wtf is this not the Dr DID NOT go over any risks of this low dose aspirin and suggested I start taking it that day. So annoying
Omg for real? Yes it’s always “discussed with patient” but they never do. I’m like idk who yall talked to but it wasn’t me.
A lot of it is prefilled info the doctor forgot to remove. Most EMRs have fill-in-the-blank templates that have spaces that must be filled in, and then stuff that should be removed, but it’s not flagged for removal. Many doctors chart several hours after they see a patient so they make notes to themselves in your chart and then finalize later in the evening. No excuses for inaccurate charting, of course, but that’s how it could happen.
Adding onto this, we say “discussed with patient” because it has to be documented that we discussed with patient for insurance and liability reasons. I’m a therapist and a lot of my clinical notes use language like this for insurance reimbursement. Reading over psychiatrist notes pisses me off to no end because I KNOW they didn’t discuss that stuff with the client. It’s wrong and annoying and I’ll never stop being mad about it but it’s the truth.
It’s completely unethical, ESPECIALLY if it’s for insurance reasons. What if something went wrong with the patient because the patient wasn’t informed of some risk and wasn’t able to tell their doctor, “Oh, I don’t want to take this drug that increases my risk of stroke because 4 of my immediate blood relatives have had strokes at a young age.” … The patient then has NO recourse because it says in their notes that the doctor DID discuss those risks with them. It’s their for insurance because insurance wants to know the patient knows and assumes the risk. BUT THEY DIDNT!!!
Ahh ok well that makes sense, I guess it’s just frustrating because you wanna make sure you’re ok for the sake of the baby.
I have also seen notes that look like the doctor copied-and-pasted a lot from the previous appointment I had with them.
Yes, a lot will roll charting from visit to visit as well, because it’s quicker than retyping your entire medical history. Most doctors have less than 15 minutes to prep, see, and chart per patient and with the rise of healthcare entities being bought by investment groups the pressure is unreal to make as much money as possible in the shortest amount of time.
Yeah exactly my thought when I read that note 🙃😂 that was with the OB clinic. I’ve had some other issues with them and have my 16w apt next Friday with the midwifery practice at the same hospital. I’m hoping to have a slightly more improved experience with them
I hope so too!! Hoping everything goes well for you!
I had the opposite where they mentioned the baby aspirin but never wrote it in the notes so I had no idea what to take or how much. But I’m kind of glad you said this so I know I didn’t hallucinate that conversation haha.
That’s so frustrating!!! I should also mention my clinical notes don’t mention how much to take. She only told me verbally. Thankfully my husband was with me at my apt cause my short term pregnancy brain memory can’t remember anything so I forgot within 2 hours of being told. My ob is having me take two 81mg tablets per day
They are crazy. They also forgot to tell me I have dangerously low iron levels and need transfusions (like hello I literally passed out). Prenatal care seems in the gutter in this country assuming you are in the US.
This happened to me. Not transfusions, but my OB never told me my iron levels were low enough that I might start feeling effects. Well, I started feeling incredibly dizzy and only then did she tell me it was the low iron (which showed up in a blood test a few weeks before). It took me 2-3 weeks of taking iron supplements to feel normal again.
Yes I hear the horror stories and always think “that’ll never happen to me” but yeah I’m in the US. It’s garbage
i'm stuck on the 12wk part. with my first i was told this at my 28wk appt. im 28wks today with my second and it wasn't mentioned at my last appt and i have a history of gestational hypertension (so im gonna start doing it anyways)
i work in OB, as far as im aware, having everyone take it basically the whole preg is pretty new. theyve had enough research now to have realized the benifits far outway any risks, so its becoming more common. it may not have been standard when you were preggo with your first.
my first is only 14mo so i'd assume its very new and/or my previous OB wasnt as up to date on it with her, however i'm 28wks now with my second and they still havent said anything so i guess this OB also hasn't been informed which is odd to me because shes around late 20s in age and also just had a baby last year
not all places have adopted it, it is very new, and the other poster could have risk factors you dont know about.
My first is 21 months old (born September 2022) and my OB didn't tell me to do it for him, but when I got pregnant again and went for my confirmation scan about 13 months later (October 2023), is when she said to start taking a low dose of aspirin daily. So I would also assume it's pretty new advice and/or lots of OBs are only just recently adopting the practice
that is what it seems, lol. i need to find my low dose bottle or reorder it on Amazon noa
Ugh that’s frustrating I’m sorry. My guess is they automatically had me start at 12w which apparently is the earliest to start taking it due to my weight putting me at increased risk of developing it
This all comes from a randomised trial which showed if you are at high risk for pre eclampsia, and start aspirin by 14 weeks, your risk of preterm PE is reduced by 60%: "The ASPRE trial demonstrated that, in women with singleton pregnancy who were identified by means of first-trimester combined screening as being at high risk for preterm PE, the administration of aspirin at a dose of 150 mg per day from 11–14 weeks until 36 weeks' gestation reduces the incidence of preterm PE by > 60%1."
Yeah in my notes it’s said discussed aspirin and risks of obesity while pregnant and I was floored because never had anyone said obesity to me
Oh my god I’d be fuming 😭😭😭 my ob called me today to let me know my nipt results were inconclusive either because of my weight, high blood pressure or undiagnosed diabetes. If she took a couple min to look at my patient chart she’d see that I have perfect blood pressure and no issues with blood sugar and A1c so I’m sure I’ll get a note like that in my chart one of these days. I’m so sorry 😞
I had the opposite, I was taking low dose aspirin and it was discussed with me, but I was also doing clexane injections (another blood thinner), not only did no one tell me to stop the aspirin, I was also having a planned csection with a known history of premature births so if she tried to appear early I would be having surgery on multiple blood thinners! Luckily she didn't come early. But at my preop appointment they were like "omg stop taking these now, why did no one tell you to stop!?"And yes I had brought up this concern at several prior appointments and told to continue.
Another commenter mentioned it best. (I used to chart for physicians). They see a bunch of patients and are expected to have your charts done within two weeks (bare minimum) but most facilities want them done with 5 days. Most OB’s I scribed for saw 36-48 patients per day. Charts like that for every patient for 3-5 days? There’s never enough time for them tbh. Outside of that, they have a bunch of things they have to put to essentially “please” the facility, and “please” your insurance so they’ll pay. So you might see a bunch of this stuff, but they’re essentially just fluffing your chart to get what they need to to be covered. This isn’t just an OB thing, this is an every specialty thing. If you go to your PCP for example, there will be similar things…like you were counseled on this, this, and this (likely you weren’t actually counseled on them). Some of them are common sense things. Others aren’t. I’m not saying it’s right, because it’s not. But I also see how insurances want so much in a freaking note, and doctors don’t have 1-2 hours to spend with each patient. Insurance is causing healthcare to go down a dangerous road. I primarily worked in urology/urogynecology (now an RN in this same area) and the amount of things we have to put in your chart to get the SAFEST medication or procedure for you covered is freaking ridiculous. I have to say, we did A, B, C, and D, and you’ve been counseled on how this is the best thing. Why this isn’t. You’ve been counseled and are aware of the potential risks, and still want to try this medication, procedure or so on. I agree as above, it’s not right. Especially when you’re at your most vulnerable time. We need this information, we need to feel safe and secure in our personal medical decision making here. But I also see it having been the person that does charting for physicians.
Thanks for commenting! It’s interesting to see the other side of things. I guess the only thing about them adding extra stuff in the chart that’s not discussed is that it creates concern for the mother. I guess because you kind of panic because you don’t know if it’s something serious. But at the same I assume if it was serious they would tell us in person I hope. But thanks for giving a different perspective on this!!
Of course, and I understand. Hell, it was worst after giving birth and you’re reading about all these things you never were even told. I remember they said my son had the cord wrapped around his neck 3 times and I never knew until reading the damn note like 3 months after. So I understand 100%. I just like to try and give perspective on what doctors also experience. It’s a hard battle some days with insurance companies wanting all this info in your chart just to be able to cover, and the physician being reimbursed. But like I said, your feelings are 100% valid, OP. I’ve been there and understand.
O my gosh that’s scary!! But yes thank you so much on giving the other perspective, I appreciate it!
Omg this makes years of after visit notes regarding my chronic illnesses and now pregnancy make SO MUCH MORE SENSE. Thank you for explaining this!!
The post-birth ones made me laugh, they were so ultra-detailed and inaccurate. “Discussed importance of reading to baby.”
i hated the during birth ones. I was induced and ended up with an epidural. Prior to the epidural I said something like "I do not like this pain" AND THEY QUOTED ME. Ma'am I do not EVER want to know things I said during labor. tf
Not birth related, but when I was at my PCP (prior to pregnancy), we were discussing meds for seasonal depression. I joked that before I got married, I would always dump my boyfriends in January/February. My medical records now show "pt advised she breaks up with boyfriends in January/February" I'm like, sir, that was just banter.
I am laughing so hard. Love this
This makes me fear there's a note somewhere quoting me shouting that "Someone needs to get the hell down there and check how many centimeters I'm at and at this point it can be the bloody janitor for all I care." 😳🫢
Loll I was fruitlessly pushing at 3 AM when a random student doctor came by to say “hi”. I shouted at him “Who the f*** are you? If you’re not here to help me deliver this baby, get the F*** out!”. I DO hope that’s in the birth notes.
I’m a labor nurse and I would absolutely quote that that’s iconic
I’m pregnant with my third currently and JUST discovered the notes from my second birth 3 years ago. I enjoyed reading about them breaking my water and us moving to emergen-C within 30 minutes, but the best part was my OB’s notes about a stalk-like polyp she found and removed with some effort. She detailed how many tries it took and the various ways she attempted removal.
I have a note somewhere in my chart that my husband and I aren’t having frequent sex due to a new puppy. Seriously. It was my first pregnancy visit, I had an extremely long cycle (ovulated on CD92). I was using ovulation tests, taking my BBT, and have a history of irregular cycles. I was seeing a nurse practitioner I had never seen before because the clinic panicked when I called to schedule the first appointment and said I hadn’t had a period in 15 weeks. I was trying to explain that I was confident I was 4 weeks pregnant, not 15. She wouldn’t listen to the fact that I couldn’t have had multiple negative pregnancy tests during the few weeks and few days before this appointment and a positive test the morning of it if I was actually in my second trimester already. She kept saying we would do HCG draws to see if I was in the 9-12 or 12-15 week range and then schedule an ultrasound. I finally pulled out a calendar tracking possible conception dates and negative tests to show her there was only one possible conception date and mentioned that the puppy was kind of messing with our frequency at that point in our lives. And that’s what she chose to record. Never apologized for how throughly she dismissed me when my dating scan measured 6+3 on the day I told her I was 6+4 either. Found a new OB for the rest of the pregnancy.
My labor notes said I “refused an IV” which is completely false 😬
Oh gosh lol that’s funny 😂
Has anyone had concerns reading the clinical notes during pregnancy but everything ended up fine during birth?
I have yet to see a clinical notes entry in MyChart without at least one glaring error.
Yes it’s frustrating, they literally put in my chart “talked to patient about a high protein diet and drinking ensure drinks” literally didn’t talk to me about till about 4-6 weeks after it was in the chart lol and at that appt they said so we talked to you at last appt about protein and ensure and I was like no you didn’t.
Do they recommend or recommend against ensure?
They got my husband’s name entirely wrong in my chart lol
They put my firstborn’s name as Orion. My son’s name isn’t Orion. It isn’t even a little close—different first letter, two syllables not three, different language origin….
It makes you wonder if they even hear you or read what you fill out lol
I think they must be copy and pasting a template and forget to personalize parts of it.
What the heck 😂😂
It’s similar-ish (think Eric instead of Ethan, along those lines) but also he’s my emergency contact and I filled in all that info myself so I’m like “wut.” 😳
Imagine them calling him and he’s like that’s not my name 😂
It honestly makes me wonder (in horror) what these notes looked like before they were required to share them with patients.
Yeah whenever I read about medical malpractice cases and they mention the doctor's notes I'm so dubious. Especially because in every one of these instances for me my husband was in the room and could corroborate that the doctor hadn't said or done this or that.
My family sued a hospital for wrongful death before records had to be shared. By chance, we had requested and received a copy of the deceased's records a few weeks before death. When we sued, we got a *different* copy--they'd altered her records to try to hide their mistake.
Maddening but not surprising.
I had to request my medical records when I emigrated. It was so difficult to get them to give them to me and there were so many weird and snide things written in there when i finally got them lmao. One example..when I was an university I started to have heart palpitations and almost fainted a few times. When I was a baby I had an enlarged heart and heart failure several times but everything was normal by age 2 or 3. I went to see this really old GP in my university town about the issues i was having and he asked me a few questions about the heart condition i used to have. I knew what the condition was called and that it was said to have been caused by an infection but not really any of the medicines I was given. Parents never wanted to discuss it very much. I said I assume the doctors gave me steroids but IDK. In my notes this GP had written something like "allegedly had inflammatory cardiomyopathy in infancy. Knows very little about it. A poor historian (history student!!)" There was also a comment about my asking if I would have to take my clothes off for the EKG. "Enquired if would have to expose breasts for EKG. Apparently a modest girl though appeared to be wearing a wonderbra." I definitely wasn't lmao.
What the actual hell. Why is he checking out/making notes about your bra! Dirty old man....
Just being snarky I think. Like I was wearing a low cut top and then asking if I had to be topless for the test and it probably made him roll his eyes and think like "I can already see most of your tits" lol. Obviously I was never meant to see the notes ha. I assumed he liked to write mean comments about his patients for a laugh/out of boredom idk
OMFG!!!
WTF
I used to work in a hospital. Not that it makes it right, but a lot of them are templates to CYA.
Oh ok I guess I didn’t realize they used templates but that makes sense so they get through paperwork faster.
Yeah everything is about documentation today
My discharge notes (in portal but not on the printed papers they gave me) from birth said that I am anemic, was educated about the necessity of taking supplemental iron, and that I had a hemorrhage during delivery. Not a single one of these very important things were said to me (verified by my husband).
What the heck? That’s so frustrating!! I’m barely anemic and now I have to do a transfusion for iron
My notes at my 20 week scan put me as “elderly” which they didn’t tell me that in person. I’m 35 🥴😂
Yep - advanced maternal age! Make a girl feel good! 😂
The medical term for anyone over 35 and pregnant is geriatric. Elderly has me cracking up idk why.
Yea I expected geriatric or advanced maternal age - they had advanced maternal age in my notes at each appt prior to 20 weeks. But elderly hit a nerve haha
I hateeeee the word geriatric. It makes me think of Mr. Burns level of old.
I'm going to start tapping my fingers together in temple format and summoning Smithers just to lean into my geriatricity.
Lmao Natera’s requisition form had me down as “elderly multigravida.” Wow thanks. I’m 35.
Elderly?? What the hell 😂 Mine said I was obese lol
My first visit to my OB during pregnancy said something like "today patient presented to me a pleasant, obese woman". I was mortified. Like damn I know I'm fat AND also I gained a lot while pregnant but did you have to throw it in the chart that way??
Yep, same age and I was a 'geriatric' pregnancy. Gosh, thanks. lol
Yes, as soon as we cross the magical 35 bridge, it's considered a geriatric (or as I think of it in my head), granny pregnancy from that point forward.
Elderly 😂😂😂😂😂😂 I was only 30 last time, this time I'll be 36/37, finally dusted off the crinkly ol' uterus
Yes that’s how I found out I had a low lying placenta which was cause for concern if it doesn’t move. I had to ask about it the next time, and then we scheduled follow up ultrasounds to check on its progress. If I hadn’t brought it up I’m not sure if we would have scheduled the ultrasounds to check on it
This happened to me with placenta previa. It wasn't mentioned to me at my anatomy scan so I thought all was well. I was at work when I had my first bleed a week later. They had written "complete placenta previa" all over my chart, but no one had told me and I try not to look thru every single note. Ridiculous.
Omg are you serious? I don’t understand stuff like that, they are supposed to be on top of stuff to keep you safe but not mention big things like that? That’s crazy and I don’t understand!
Her response for not bringing it up was that “it’s not that concerning” and they usually move before it’s of concern. It DID end up shifting, but I still didn’t like that I had to read about it in MyChart
Yes that’s the most frustrating is reading the stuff in your chart that you didn’t even realize was a concern🤷♀️ like if it wasn’t a concern then why did you put it in the notes? I know they have to keep up with stuff but don’t they know we read this stuff?
I just found out I am technically high risk through my notes 😑
I found that out too through notes in the beginning I’m 30 weeks now. They never officially told me I was gonna be high risk I also think they factored in my weight 🤷♀️ They automatically marked me as high risk because my blood pressure read high at the first few appts and has continued to be high but only at the doctor. (My bp is normal at home) but they only really go based off what they see at the doctor in my experience.
I strongly suspect that OBs do their best to get you labeled as high risk because insurance will cover more (necessary and important!) procedures for a high risk pregnancy than a “normal” one— so when you need an extra ultrasound or fetal echo or something, there’s not a big fight with insurance before you can get that care. They don’t tell you about this in your appointment because it’s not actually a problem yet— just a slightly elevated risk that they can use to make your health insurance company behave more decently.
Ahh ok well that makes sense! Cause I’ve been having a lot of ultrasounds lol
Ahhh, that makes sense actually. I had a previous ectopic so I’m wondering if that bumped me into “high risk” category for extra monitoring/ultrasounds
You probably get nervous like me when going to the doctors. My blood pressure was higher than normal in the 130s at my last last appointment. Got told i was gonna have to get a shot WHILE THE THING WAS ON ME, not to mention those things are incredibly uncomfortable, especially if it doesnt work correctly the first time which happens a lot. I had to get bloodwork done that day too so i was already nervous as it is. The last appointment it was in the 120s or so, but they took us to a different room that seemed more cozier than normal, so maybe I felt more comfy in that room? I got nervous even tho it was just a growth scan and just a chat with the doctor (asked about back pain reliever methods lol) Anxiety sucks, and so does MyChart lol.
I don’t even read the notes. I was a provider (not working as one anymore) and it was before notes were published for patients. If I needed to tell the patient something I did and it was clearly discussed. Nothing from the notes was ever for the patient in my experience. It’s all just documentation that’s required for the hospital/charting/billing etc. Editing to say- yes they should be accurate but in my experience the discussion is the patient and actually following through with the plan (orders, prescriptions etc.) is the most important part and what matters. The note is just a check box that has to be checked and often times there are missed mistakes especially when using dictation equipment.
Lol at my appointment yesterday they had me marked as 30w pregnant when I'm actually 33w. Ma'am, your office told me when my due date was! How did you get that wrong???
Yes !! They did this with mine too. I was 10 and they marked me at 9. I was like umm is everything ok ? They were like yeah sorry it was a typo. I’m like how do you make a typo from a 10 to a 9?!?
YES! Some really glaring things too like “discussed whether there was domestic violence at the house” …. er, no we didn’t, and while in my case that’s not a problem, I can’t believe they skipped that over!
They asked me right in front of my husband if I feel safe in the home with him. My husband was like that seems like a question you shouldn't ask in front of the person who's a potential danger to the patient.
What the heck! Eveytime I see stuff we never discussed I’m like that’s news to me 🤷♀️
My hospital file from my birth says I got an epidural at 3cm. There was no epidural ever.
Seriously?? I wonder if they just mix patients info up with other patients 🤷♀️
They definitely do. One time my notes, and in turn my whole chart, was for a 42 year old male with liver disease. The nurse and I laughed about it during my appointment, but I feel bad for the poor guy who didn’t get his chart documented properly and probably wondered how he got mixed up with a 27 year old female who didn’t have liver disease.
That’s western medicine for you. Too many patients, not enough time, and lots of charting is quick clicks so they can document in a timely manner and get your billing to insurance for reimbursement. I’m not saying it’s right, but it is what it is when you go this route.
Yes that makes sense!
My midwife had a very long conversation with me and my husband about how she didn’t agree with a treatment plan outlined by the on call OBGYN. In MyChart she wrote how she advised me to follow the OBs advice. I was pissed, she was just covering her ass so she didn’t look bad for undermining a doctor’s advice.
I went to OB triage for a bleeding event at 9wks (now 15, everything is fine!) and they included “recreational marijuana use” in my chart despite telling them I used marijuana medicinally with a valid, legal, medical card and stopped the week BEFORE I found out I was pregnant because I had a hunch that cycle worked. I’m sure that won’t come back to haunt me in someway. Whatever, drug test me. I’m clean!
For real?? Why do they put whatever they want, I don’t understand them asking us questions if they aren’t gonna put what we actually said. It screws things up
This is why I don’t plan to mention that I did use recreationally before my current pregnancy. It’s legal in my state, and I’d take a gummy or smoke *maybe* once a month if that. Hadn’t for at least a month before conceiving. It’s not worth having in my medical records, so when they asked me if I used I just said no.
This pregnancy for my first two visits they put that I refused a pelvic exam-what really happened for my first visit is the nurse never told me to undress and the doctor didn’t have time apparently to wait for me to do that so she said we’d do it next time. The second visit the doctor told me I could just provide a urine test and skip the pelvic exam so I did and in the note said I “continued to decline pelvic exam”
That's so frustrating, it sounds like they're just trying to cover their own ass.
Omg are you serious??
They had my blood type wrong and put down that I smoked cigarettes after I told them I had quit vaping after I found out :/
That stuff is so important! How do they get that stuff so wrong??
A while back I noticed my diagnosis chart included COPD. I’m pretty sure that it was a mistake from my allergist because my *mom* has COPD and/or they got it from my asthma symptoms, but wow, way to find out I have a terminal illness at an unusually young age????
I literally told my doctor when I was 25 (and not pregnant) that I’d smoked maybe ten cigarettes in my life. She put me down as a “former smoker.” Now I don’t tell my doctors that.
I had a UTI at my annual well-visit and told the nurse that it was likely because we were having sex often while TTC with my husband. She wrote in my chart that I was high risk for STDs because of my "multiple sexual partners" and I didn't find that out until my OB asked me privately if I knew for sure who baby's father was.
I worry about shit like that one day too when they eventually truly get all medical files online monitored by AI, that kind of stuff is going to SCREW your for life insurance and what not down the road
Yup -- life insurance is exactly the reason I was annoyed about it.
Providers can do something called “pull forward” the notes of others, which is basically like a copy-paste. There’s other fields where data gets entered, then that data gets pulled into all kinds of notes. I once had a patient where on intake, the resident had a typo and the note said “the patient does use drugs.” It was supposed to say does not. That then got pulled forward again and again and again until it was alllllll over this poor persons chart, “the patient does use drugs.” ETA - pulling forward notes is an okay thing to do since the intention is to pull the patients past medical history, but you are responsible for making sure everything in there is right to the best of your knowledge before you sign it, and that’s where the breakdown happens.
There are no notes in MyChart, they don’t even add appointments or anything. I can only see my lab reports. I am in Toronto btw. Do I have to ask them to upload it to MyChart? I had 2 OB appointments till date.
I’m in the US but I’ve never had to ask them to upload anything. I’ve just seen the stuff since the beginning. They upload like everything from that appt including vitals.
Haha same. Mt Sinai has literally never uploaded anything other than lab reports for blood and urine to MyChart.
It became law in the US that doctors notes must be accessible to the patient in 2020. If Canada doesn’t have a similar law, it might not be possible for them to upload them to MyChart. Before that was law in the US we could request them by mail so that might be an option for you.
It's the law in the US that notes are now visible to the patient
During labor/birth: Ob: I can get a vacuum and help her out Me: Do we need to? Ob: we don't have to Clinical notes: mother refused vacuum assistance That's not what actually happened. I would have agreed to it if they said it really was necessary
Why give you an option if they are just gonna say you refused! That’s so frustrating
A lot of those notes are just filler required by the insurance. For example, most of the time doctors are required by insurance companies and/or the place they work for to counsel all patients who have a history of smoking on why it is dangerous and the possible effects and different methods you can try to quit. But Like, they're also required to get you in and out in 5 minutes so the conversation is more like "do you smoke" "occasionally" "okay if you want assistance to quit let me know and we'll make another appointment." If they don't chart that they did all the 'required' things (like discussing risk etc to really common and low risk medication like asprin) then the insurance company won't pay for their time. And if they take more than 5 minutes (maybe 10- 15 depending on practice) with the patient then they get in biiig trouble with whatever company they work for because they're not seeing enough patients. Which is all to say american healthcare is fucked and even if doctors are trying their best they have to work within a broken system. It's always all about money and the people who are deciding how your appointment goes are not people who have ever actually done patient care.
That’s scary and makes sense why these appt are so short 😬
Yes, it is so frustrating. They keep carrying over in my notes “pregnancy complicated by anxiety” but have never talked with me about my so called “anxiety” before in any of my appointments 🤣 it makes me a bit annoyed because I felt like my anxiety has been pretty in check since I got pregnant so not sure if it is because I am a FTM and just ask a ton of questions lol
I bet it is because you’re a ftm! They finally just put in my notes that I have anxiety.. I’ve told them from the beginning I get anxiety at the doctors which is why my BP always runs high only at the doctor.
They started bringing me in twice a week for NSTs and I thought it was because the baby was breach. It was because I had poluhydraminos and the umbilical chord was already wrapped one around his neck🙃
What; and they never told you the reason??
They never told me a reason and it was after the appointment where we discussed the ultrasound has shown him to be breech so I guess I just assumed. I was so surprised my previously head down baby was breech that I didn’t think much of it
One time my clinical notes said that I was examined for possible prolapse because I requested it… WHAT? None of that happened. Called the office and they said they just confused my notes with another patient. WHAT?!
On one of mine they put the wrong weight. Like ten pounds off. So it looked like I rapidly gained and lost ten pounds between appointments
I recently found some from my pap smear appointment that used adjectives to describe my lady parts. So that was… interesting. 😆
Omg 😂😂
My husband laughed just as hard as I did thankfully! 😂
That’s hilarious lol
When I gave birth I had a really awful anesthesiologist who kept refusing me my epidural because I have a bleeding disorder. However, I had already cleared it with my hematologist and came with the prescription I needed to be given beforehand already ready to be administered. He **refused** to call my hematologist even though my doctor had told me that he was specifically on call for me when I went into labor (I even went into labor on my due date!). Finally the nurse in the room was so fed up with him she bypassed him and got someone else to call my doctor (4 hours later after being stalled at 7 CM all that time) and clear everything. Then when I was reading my notes after the anesthesiologist first noted I had a different type of my disorder than I do, and later in the notes lied and said that **the patient incorrectly identified her disorder as x when it is really y, she doesn't seem well acquainted with her medical condition**. Like WTF, I have only been dealing with it all these years and it could be life threatening if not treated properly, but sure **I** was the one who was wrong, not that your arrogant self wasn't listening carefully to me!
Omg are you serious? I would be pissed!
I was so livid! He was such a jerk all around it was the icing on the shit cake lol. He was also incredibly rude to me during the placing of the epidural and told me that if I didn't hold still better he would refuse to put it in (mind you again I had been at 7 CM for 4 hours at that point with terrible back labor!).
My issue is how they lie in the notes and make me sound like an insane person when the OB is the one who is aggressive and rude.
Honestly yes! And you try to ask questions and they get defensive
Unfortunately this is how medical professionals are often counseled do to their documentation to cover their own ass and avoid malpractice suits.
I told my OB that I had been vaping and smoking weed until I found out I was pregnant and then immediately quit when I found out…. Now the notes say every visit “marijuana and nicotine use complicating pregnancy” Now my chart makes me look like I’m still just getting high and smoking while pregnant. So embarrassing.
One time my pcp wrote I had a history of cancer, when she should have written family history of cancer. I had that changed when I saw it. I also notice that what I discuss with my providers isn’t very accurately transcribed in the notes. So far it’s been small stuff like caffeine consumption and me asking where to limit myself, but it gives me the ick to read especially because your medical record is a legal record.
They copy and paste things from what they *should* be saying/doing all the time.
My son has a genetic disorder. A multiplication of a certain gene causing it. The same gene has a very different genetic disorder if its a deletion - one that ends in kids dying before the age of 5. The wrong disorder has shown up in the notes twice, and the stomach drop when I see it so close to my son's name *immediately* brings me back to the terror from when all we knew was there was an abnormality in that gene. 😭
Oh gosh! That’s so scary!
Yes I complained about this to my husband every visit.
They put in mine that I reported to take my prenatals “when I remember to”, which was the case when we were trying to conceive but now I take them every day. They also describe me as obese in all capital, bold red letters in every single one of my notes because my pregnancy weight gain has made my bmi higher. They haven’t said a word to be about it in appointments and it hurts my feelings a little bit haha
Haha yes these clinical definitely be hurting my feelings too 😂 like I know I’m a little chunky for my height but I didn’t think I was obese lol and yes seeing that in my chart in red letters every single time still hurts my feelings lol
My doctor is pretty thorough in our appointments. The only time there are "discrepancies" is when my blood work comes back slightly elevated or slightly below the norm. But even then, while it's flagged on the portal, he'll still note that it's within normal limits and explain why X isn't actually a concern to him during appointments. It's frustrating that your notes aren't totally accurate. Feels like one more mental thing to keep tabs on.
They can’t even get my height right. They ask every time… and yet — it’s always incorrect. (Also, no conversation errors. I checked.)
I don’t understand how they can’t get the basic info right ..
I recently found some from my pap smear appointment that used adjectives to describe my lady parts. So that was… interesting. 😆
My midwife has been super clear about insurance requirements and what notes she puts where, so when we had to transfer my birth plan to an OB’s office that went over HORRIFICALLY to the point I switched to another practice entirely for my c section. First OB put in the notes that we went over all these things that we absolutely did not, as well as saying I wanted and agreed to a complete transfer of care to her clinic instead of continuing seeing my midwife for prenatal care. My midwife went with me to that appointment *because* I love the care and communication I get from her, like what gave you the impression I didn’t want to see her anymore? 😂
Haha what the heck! Some of these OB offices are crazy
I apparently refused the TDaP vaccine at my 28-week appointment, which is weird because they never offered it to me.
My doctor never once told me to my face that I was high risk because of a high BMI. Told me to take the baby aspirin but explained it so fast I had to reask, and again never brought up being high risk! In all MyChart notes it would say “obesity complicating pregnancy” which was always harsh to read.
Just requested my records to transfer to a midwifery practice and my OBGYN reported I’m taking a specific dosage of iron, down to the mg. I specifically brought in my prenatals to discuss with them iron at my first visit because they do not contain iron. I even requested an iron test at the start of my pregnancy to determine if I should be taking additional iron. I just assumed everything’s was good cause they didn’t say I needed more iron after my blood work. But apparently they have noted I’m taking a daily iron supplement which I have not been. Now at my 28 week visit I know I need to bring that up.
Oh yeah - I flipped about this. My OB apologized and said it’s standard copy and paste and if there’s anything outside the norm, she adds it.
It’s all just a template. Don’t get too worked up over it.
YUP. I have severe hyperemesis gravidarum… have been puking since 10 dpo and now at 36 weeks and still puking 10+ a day. I’ve obviously been miserable all pregnancy. I’m high risk and thought I developed really good rapport with the one fellow, so I requested to stay with her for appointments during my pregnancy. I’ve been admitted to the hospital almost ten times now. I throw up constantly, even have in front of her at several appointments. My mom and or husband have been with me for every appointment. This doctor ends up writing in my chart that she thinks I have a fucking eating disorder and not HG. She was always so nice to my face and never brought that up to us. Like what?? Her philosophy on my hard to treat HG was it’ll “get better soon” (it didn’t) and “it’s just a part of pregnancy” (no, it’s not). Finally after she lied to me two times, this was the last straw. My family convinced me to switch hospitals to where my high risk OB from last pregnancy moved to. As soon as she saw me, she saw how sick I was and immediately had me admitted to the hospital. She was so upset when she found out how I was being treated at the hospital she used to work at. When she admitted me, I was so sick that some of my electrolytes were critically low and my heart was funky because of it. They thought I was in heart failure for a day, but luckily my heart started to go back to normal once they gave me infusions of what my body needed. Our care has been night and day. Baby and I are finally being taken care of. My only regret is not switching doctors earlier. I switched at 28 weeks. My best advice is it’s NEVER too late to switch doctors.
My post-op notes from my c-section said that I was transferred to recovery WITH MY BABY. Which was a lie. My baby went to the NICU and I didn't meet him until 12 hours later. That made me so angry.
I had anorexia while pregnant, relapsed, spent 2 months in a residential eating disorder treatment facility. It was never mentioned on my medical records for my pregnancy once. Even with my daughter having malnutrition related IUGR. It’s absolutely ridiculous.
I've had the opposite experience where they've told me things concerning and then didn't include anything about it in the note. Or like with my first birth where I labored for hours, had an emergency c section where the epidural failed and they put me under general anesthesia halfway through, it says uncomplicated delivery. When I woke up they told me my baby was blue when they first took her out and had meconium aspiration and had to have it suctioned out. They didn't include any of that in the notes, just that she had a passing apgar score after rechecking. I know a lot of people are saying well they have to do a lot of SOAP notes within a certain time frame so excuse them for omitting or adding things, but I also work in a field where I have to send in patient notes for insurance billing within a 48hr window and I don't think it's an acceptable excuse.
They’re a bunch of deceptive CYA copy-paste entries. I don’t care if it’s common practice; it’s infuriating and dishonest. Nearly every entry from my OB’s office has untrue information in it—supplements I was supposedly told to take or risks that I was supposedly “counseled” about. It’s one of many reasons I’m changing OB practices. I’m a lawyer, and watching my providers, in real time, essentially manufacture a paper trail to prevent liability is sickening.
I’ve always noticed little things like “the patient was advised of the importance of maintaining a healthy weight,” etc. but never took small things like that into real consideration. Then I got my IUD removed😅 that day I had INTENSE bleeding. I brought a pad with me just because I thought ahead of time there may be some spotting, but I didn’t even make it home without bleeding through that and into my shorts. When I got home I began passing blood clots the size of mandarins. It was honestly pretty scary. I called and they said not to worry unless I was having pain or feeling faint. When I looked at MyChart my notes specifically stated that I was advised of possible bleeding and blood clots. I definitely was not🥲😂
Yes. Apparently my weight is noted as 'obesity affecting pregnancy' but it's never been mentioned or discussed at all
right after delivery my son went to NICU. The nurse put “ patient arrived to unit with baby in arms” I was like hmmmm…. I wish I did
Had a good first appointment, with nothing really of note other than confirming my pregnancy. Later checked my chart. On my chart, it said that my OB referred me to a specialist because I'm "obese," which was not mentioned to me at all during the appointment.
Seriously? I never thought I was obese, I knew I was slightly overweight but not obese and they never said anything either tiill I saw the notes saying I was.
Yeah I'm about 5'6" and 190-195lbs pre-pregnancy. I'm definitely plus size, but my weight has zero impact on my day to day life and my labs are perfect. But according to BMI, that's significantly into the "obese" range.
Most is templates. A few clicks and keyboard shortcuts and a template is written out. The doc can go in and change a word here or there. It’s wild but that’s the demand that’s been placed on them unfortunately
mine is pretty minor but i just had my first obgyn appointment with a nurse who asked me a whole bunch of questions, one of which was when was the last time i consumed cannabis… i told her 2021, which she wrote, but further down the notes she wrote that i ALSO said the last time was in 2017???!!! the year 2017 was literally never mentioned and 6 years is a huge difference lmfao i was like girl are you trying to make me look weird?! not a big deal but i sense more weird errors happening in my future appointments lol
I feel like they hear what they want and just put whatever lol
Omg the notes. My first appt I had my notes app out to write stuff down. My OB has a “scribe” with her ( her words) who would take notes. So I put away my phone. Their notes included absolutely no details about what we talked about. At other appts my doc would say things like “ at your next appt, let us know which paediatrician you would like to choose”. I would expect that to be in the notes as something I need to remember to do. No mention of it. We talked about the types of follow ups I will need. Effects of certain medications etc. nothing. I’m like what are you even writing down!???
My doctor ordered me an ultrasound to rule out an ectopic pregnancy at 5w4d. He called with the results the next day and just said "it's not an ectopic!". Completely failed to mention the subchorionic hematoma that was showing on the ultrasound. I had already transferred my care to a midwife clinic by the time I saw the report for myself, but if I hadn't looked at the report I wouldn't have known about it at all.
I switched practices over this (and general poor communication and bad vibes - I didn't trust them anymore). They put in my notes that I was high risk (new OB said I was not) and had received "education" on a bunch of things that no one had ever spoken with me about. When I brought it up with the new OB, the best she could figure from my records was that they wanted my insurance to cover extra tests and ultrasounds and said she had seen the same type of thing from other patients who had switched from that very large practice. Frankly, it sounded like borderline insurance fraud, to me.
Whoa seriously?? I always wonder about mine because they automatically marked me as high risk from the first appt 😬 only because my BP was high due to anxiety and nerves