Recently, my daughter’s endocrinologist took an “extended leave”, and since we we needed to have a doctor for her. We returned to her previous one who is in the same group and referred her to her current doctor to see if he could do a better job of controlling her glucose. After returning from his leave her current doctor gave us the office notes the covering doctor had written during our visits. I read these, and was very upset over the contents.

He wrote a bunch of untrue statements about my daughter and myself. Things such as our lack of ability to care for her, lack of regard in doing bolus and correction doses, overfeeding her, and even personality conflicts between her and myself putting her in a dangerous situation — all of which are untrue. He said he had talked to us on numerous occasions, and we regarded it as a less conscious act. All of these things are so far from the truth; He never mentioned anything to us. I have spoken to her other doctors about this, and they know that it so far from the truth.

Is there any way that I can have these statements removed from her medical records. It really upsets me to know that they are in her files. We live diabetes 24 / 7 ; 365 days a year. She is a very happy child, and he even regards her as a pleasant child. Small for her age, and nothing to say bad about her health except her out of control blood sugars, which have been this way from the beginning, in spite of all we do to make it right. Please help me to know how to handle this. Have you ever known of a case like this? Who do you recommend for me to talk to?

You don’t tell us what your daughter’s hemoglobin A1c is which would be a good gauge of how out of control her blood sugars are nor what her insulin regimen is (i.e., whether she is on Lantus (insulin glargine) for basal rate insulin with Humalog or NovoLog just after meals adjusted for the premeal blood sugar and the number of ‘carbs’ she actually ate. I wonder too if you have discussed using an insulin pump, a plan to consider even though she may not be in very good control.

Perhaps though the most immediate step would be to discuss this problem with the Medical Social Worker in the group, if there is one. A final suggestion, that may already have been looked at, would be to arrange an anti-glutamyl transferase test for celiac disease which is another autoimmune condition that occurs in about 8% of children with type 1A (autoimmune) diabetes and can be a cause of poor control. At the same time, it would be worth getting a TSH blood level for thyroid function and another marker for the autoimmune Autoimmune Polyglandular Syndrome syndrome. Achieving good control is much more important than what may be written in the medical record.

DOB
Additional comments from David S. Holtzman, Esq.:

The notes that you speak of are the work product of the physician. As such, you do not have any right to add to or change them. However, they cannot be released to a third party without you or your daughter’s permission. In addition, in some states, you have the right to add a statement disputing these comments should these records be used by an insurance company to deny you coverage or for an underwriting decision. Two other options are to file a complaint with the state board that licenses physicians or seek the advice of an attorney with experience in health matters to see if you have a cause of action in libel.

DSH
Additional comments from Dr. Larry Deeb:

My understanding of the new regulations give you access and the right to “correct” records. I would interpret this as the right to put your thoughts in the records, just like you can in your credit report. The doctor and you are entitled to your thoughts and beliefs. I don’t think you can have the doctors statements removed.

LD
Additional comments from Dr. Stuart Brink:

You cannot control what a doctor or anyone else writes in a medical chart, but, you have the right to respond to all these statements and write a letter to the first doctor requesting that your letter also be placed in the medical record to counterbalance what is currently there. You should also feel free to discuss this with our current physician or nurse educator(s) as well.

SB