Records

I received my medical records from my RE’s office last week.  Initially, I let the whole packet sit untouched.  Why do I need to read records of things that I lived through?  It’s not like I wasn’t there speaking to my doctor every step of the way.

Eventually, curiosity got the better of me.  I grabbed the envelope on my way out the door one morning and flipped through it on my lunch break that day.

Here is where I offer some advice.  If you are ever given a stack of your medical records, and your emotional state is perhaps already fragile for one reason or another, don’t read them.  Just don’t.

I learned that there are things doctors write in their notes–because they have to–that perhaps you don’t really need to see spelled out on paper.

For example, we all know I was spotting quite a bit early in my pregnancy.  It started the day after my first positive pregnancy test and continued through about 6-ish weeks.  My low initial progesterone level had them watching my hormones very carefully, and beyond that, nothing much was ever said about the bleeding except to watch it and let them know if it worsened.  We all know that bleeding in pregnancy can either be something or it can be nothing, and my doctor reminded us of that every step of the way.

In her notes, however, bleeding = threatened abortion.  Those words are scrawled across the paper on her notes from every single ultrasound, including the one that details our “missed abortion.”  Even our last ultrasound with her–when everything looked good and I hadn’t had any bleeding for weeks–noted a threatened abortion.  Under her “Plan” it lists “Spontaneous Abortion Precautions.”

I haven’t been able to get those words out of my head ever since I read them. It caused all sorts of feelings. Fear. Sadness. Panic. Initially, I was even resentful of my doctor (who I LOVE) for not really discussing it with us.  Except she did.  She just didn’t use those exact words because she is a human being as much as she is a doctor. You are all witnesses to the fact that I was well aware that bleeding could equal something bad.  And even when all of the bleeding stopped and had for weeks, losing one baby certainly didn’t bode well for the threatened abortion notes, either.

I really, really wish I had just left that envelope sealed and handed everything over to my OB without a second thought.  I didn’t need those words in my head, and my RE knew I didn’t.  I wasn’t any less aware of the risks before I read her notes, and now all I can see is those awful words–even after yesterday’s amazing scan.

How amazing would it be to just be a normal, oblivious pregnant lady?  The ones who automatically assume that unprotected sex equals pregnancy or that two pink lines equal baby or that two heartbeats equal twins.  It’s hard not to be a bit resentful of that kind of ignorant bliss.

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12 thoughts on “Records

  1. I had a miscarriage at 7 weeks a few years ago and they kept referring to it as an “abortion” on my D&C notes (which I read without my doctor’s knowledge). I wanted to scream “An abortion is a choice! I didn’t chose to lose this baby”. I think they need to be clinical to distance themselves from the pain of their profession. I can’t imagine how many patients they deal with that don’t have positive outcomes…it has to be really tough.

    Rub your belly and tell that baby how lucky you both are. Now is a happy time! Hang in there and put the chart AWAY (or burn it!).

  2. Sometimes doctors write things like that on any record keeping items because if they don’t, they honestly will have no idea how to broach their communication with you. They see lots of patients a day, and generally forget the little specifics of your history, so I think the note is there so that people who handle you are aware of certain events in this pregnancy’s history. Now, “threatened miscarriage” could certainly be replaced by something like “bleeding weeks 5-7” or whatever, which is a symptom rather than a diagnosis. I’m sorry you read it. I would’ve too, and would have felt a bit slighted as well. And I too, am super envious of women who can get pregnant easily and go through pregnancy like it ain’t no thang. Soon enough though, you will have that lil baby in your arms!

  3. I work for a health insurance company and when i first saw the term “abortion” i would automatically think the worst. I quickly learned that “abortion” is the medical term used in medical records for miscarriage. My stomach still drops every time i see it because i only knew of it to mean one thing. I’m sorry, i hope your heart heals soon (as much as it can).

  4. I’m sorry you had to read that. I’ve contemplated getting my records from my bed rest and delivery, but I’m worried that it will scare me, and scare me enough to not have another baby. One of these days I’d like to get up the courage though.

  5. Sometimes we have this insatiable urge to know things, even tho we probably don’t really want to know them! We went through something similar when we got copies of our paperwork to give to our OB. Some of the terminology was less than kind and overly clinical. IT suck that you had to read that, but if you can remember that these are happy times and that your little baby is growing those words will slowly dissolve…or at least I hope that for you…sending love and hugs…

  6. This is so tough. Others have responded far more articulately than I can but one more in reply to your final paragraph: Getting this sort of information as a precaution, in advance of pending outcomes, or even as things are happening, is very different from finding out what information was available and not shared after the fact. I’ve been thinking about this a lot lately–both in terms of mixed emotions about not being able to fully enjoy my current pregnancy (I’m both glad I don’t take it for granted and sad I can’t fully commit to believing there will be a baby at the end) and about my current diagnosis (what are they NOT saying for fear of scaring me versus wanting to limit myself to only the necessary, medically actionable information) as well as earlier genetic testing (namely, the difference between forewarned-is-forearmed and very-little-that-you-say-could-change-my-desire-to-maintain-this-pregnancy, but also, a little bit, our having tested for the chromosomal sex of the fetus and my not being okay with the information being out there in a chart somewhere and my not knowing it, despite my long-standing inclination to be surprised by that info at birth). Anyway, long comment with lots of parentheticals, but all to say, I hear you and I’m sorry it’s been a struggle to relive those moments in that way. History is hard when it’s raw.

  7. I’m so sorry you had to read those words, and I hope you can forget it soon! I write clinical notes throughout every day that say things I would never want my patients to read and I would not say to them; it’s not because it’s a secret, or things I wouldn’t discuss with them, but the clinical notes are just written differently. Doctors have to remember interventions you did with the patient, and you have to cover your own work in case something goes wrong, and writing things out diplomatically would take too much time and you may forget the actual occurrence. I’m sure your doctor would never use such harsh language with you. In the psych field we strongly discourage patients from ever formally requesting their own charts because it can be emotionally harmful to read them – in fact, I can’t imagine reading my own therapy chart, what a mess they probably think I am! Anyway, I know you already know this stuff, but I hope this helps. I’m so glad your baby is still with you and I’m sending you all some love and continued healing.

  8. my bleeding scares were all billed to insurance as threatened miscarriage. definitely alarming to see that even though you know what’s really going on.

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