As a Naturopathic doctor, I have often asked my clients to provide me medical reports from their physicians.  It is a way of me gaining a more comprehensive view of what is going on.  While these reports provide very helpful information, I want to present some common issues I have discovered:

Medication list – clients will tell me they are only taking 2 medications but the report will have 6 additional ones that they stopped taking a while ago.  This may be due to just carrying over information from previous chart notes without double checking the work (I discussed this in a previous article, Racial Bias May Be in Your Medical Reports) or perhaps due to the desired instructions communicated by the physician to their patients about what medications they would like for them to be on.  If it is the latter, then there should be a list for current medications actually being taken vs those prescribed.  I tell my clients when I notice this.  They are encouraged to tell their physicians to take old medications off the report.

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Comments about other health professionals you are working with or the therapies they are implementing with you – As a Naturopathic doctor, my clients have often told their physicians that they are working with me.  In addition to just stating they are working with me, my clients often express to their physician positive things about me or the positive changes they are seeing while working with me.  Sometimes during the office visit the physician will verbally express gladness that what I am doing is helping, but mostly what ends up in the chart note is 1) a neutral statement saying they are working with me and/or 2) a statement of caution or concern that may or may not have been misinterpreted.

Example: A client told her new physician about a blood pressure medication prescribed by a previous physician that she still takes that recently made her dizzy when she took too much of it when trying to compensate for skipping a dose.  She also mentioned a therapy I implemented that has helped her feel better overall.  However, in the chart note the physician reported that sometimes the therapy I implemented makes her dizzy.  I caught it and told my client to tell her physician to correct that in the chart note.  The carrying over of false information in chart notes – as discussed in this previous article, Racial Bias May Be in Your Medical Reports – is not okay and needs to be removed.

Severity of disease – One client mentioned to me that she had fatty liver.  I discovered through the medical report that her case of fatty liver was deemed severe.  The client was never told about the severity, but just that diet and exercise would help, and even that statement seemed to be communicated without a sense of urgency.  I was the first one to tell her about how severe it was.

Diagnoses – The medical reports list diagnoses.  One client I was helping while working for a physician was under the impression he just had one condition.  I discovered in his medical report that he was additionally diagnosed with kidney disease.  Furthermore, the physician incorrectly staged the disease.  The physician had not previously told him about this additional diagnosis because she considered the disease ‘minor’ in severity at the time, it could be reversed based on what she was trying to implement with him, and she did not want to scare him.  I disagreed with this logic.

As mentioned before, I also get tons of valuable information from medical chart notes.  But in the cases where I find discrepancies, I let my clients know and I suggest to them that they request it be changed.  This is something you can do on your own by periodically getting a copy of your own medical reports and reviewing them.  2-4 times per year is likely sufficient depending on how often you visit each doctor.

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