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Wednesday
Dec222010

Charting: Whose Truth?

A brilliant piece came out December 2, 2010 in Birth Sense. “Five Reasons Your Doctor/Hospital/Midwife May Not Want You to See Your Medical Records,” caused a flood of trying-to-read-my-chart stories to fall from my brain into a jumble of scribbled-on papers, too many of which making no sense whatsoever. 

When my niece was entering Medical School, she had to present about a trillion pieces of documentation, one of which was her entire life’s medical records. Of course, we pored through them, reading her history through the eyes of care providers. While many of the entries were barely legible, one doctor in particular wrote in a hand that knew nothing but straight lines with an occasional twitch of the pen upwards. The overseeing committee considered sending her back to the HMO to find the doctor and ask him what he’d written. The notation was from ten years ago! 

I’ve read charts and written in charts for many years, even studying charting manuals to make sure my notations were medically and legally accurate. (A couple of books I've used were Mosby's Surefire Documentation: How, What, and When Nurses Need to Document and Charting Made Incredibly Easy.) But, through reading what other health care providers have written, I am continually reminded that much of charting is quite subjective. This fact alone should (in my opinion) comfort many a woman crying over the stupid things someone wrote in her chart. All sorts of things can affect what the provider (nurse, doctor, midwife, chiropractor, etc.) chooses to document. If they’re having a crappy day, their attitude colors the descriptions of what’s in front of them. A happy midwife might write (in shorthand, however): Patient concerned about weight gain. Whereas a cranky midwife might write: Weight gain excessive; counseled patient. All sorts of life situations can affect the tone of a provider’s notes: marital satisfaction, health, ingrained beliefs about certain races or gender… even religious prejudices or, what many of us encounter, disagreeing with the doctor’s advice. 

My own kids’ records are a study in annoyance on the part of the nurses (mostly). I would not let them take my kids’ temperature rectally; this was the standard of care in the 80’s. All over their charts: Mother refuses rectal temp. Sometimes with a giant exclamation point to reiterate their disgust that I dare defy their protocol… and near-shoving me, trying to get me to do what they wanted to do. I didn’t care. I wasn’t going to risk having my children’s bowels perforated. Tough if you don’t like it (was my thinking). 

When it comes to our maternity records, it can be scary to see what someone thought about us, how they perceived our choices and actions. Reading cold observations like “Patient refuses to take prenatal vitamins” can be disconcerting when the reality was the ones you tried made you throw up. 

The worry and fear can really take hold when we order our prenatal, labor and delivery and postpartum records. Reading what you lived through can be surreal; what’s on the paper all too often totally disagrees with a woman’s memory of her birth. What annoys me greatly is the medical record is considered The Truth, is used in court as the Be All and End All of what happened at the birth. Can I tell you the crap I’ve read “documenting” a birth I’d doula’d and knew the details of very clearly? I’ve seen exaggerations of a woman’s pain level, nasty comments about a family member’s behavior, mis-timings of when a mother started pushing and more. What must a mom think reading her chart without someone to let her know, “This is bullshit.”? 

Birth Sense’s post gives examples of the challenges women face when they want to get their records… how people lie about who the chart belongs to, charge them huge fees to obtain their records (I had to pay $50 to get my records from Tristan’s hospital birth) and women having their charts physically ripped out of their hands. I encourage women to find a friendly midwife who will order your records for you and perhaps going over them with you (for a consult fee, of course). If you want your records without the consult, no problem; they are your records. 

When you get your chart, please remember the subjectivity of what’s written in there. Post-cesarean moms in particular half close their eyes as they read what’s written about why they had a surgical delivery. Over and over I’ve heard moms tell me, “But they said <fill in the blank>! They didn’t tell me there was <fill in the blank>.” The chart can reassure a mother wanting to have a VBAC (was there a single or double layer suture [which, by the way, isn’t charted quite often, so the assumption is it was a single layer suture… the conservative route], was the baby acynclitic or was there a nuchal hand… variations not likely to repeat with the next baby. The chart can also bring the memory of a birth crisis crashing over a woman’s body and mind. If there were near-death experiences with the baby or dramatic hemorrhages for the mom (for example), reading can mean re-living; take exquisite care of your Self as you open the folder. 

Along with the “the doctor didn’t tell me that,” comes “They are wrong!” Twice I’ve seen the gender of the baby written incorrectly. Not that it’s funny, but I chuckle thinking about that chart being used as an exhibit in court; is it an accurate account of what happened? Or was the person that was too oblivious to note the gender correctly also too oblivious to record the mother’s overdose of pain meds. 

So, if you do get your chart, as you read, take what’s said in there with a salt lick (as opposed to a grain of salt). If you find notations that are flat out lies, you can petition to get the chart amended. If you don’t do that, you might not be able to convince another provider that what’s written is, in fact, false. But, even if the exaggeration/lie/mistake remains in there, at least you know the truth and a sympathetic provider will certainly take your words under advisement. 

All of this does not imply that every chart has patent lies or glaring mistakes written in them. We’re taught to be as objective as possible, but, as humans, that isn’t always possible. I'd even say the great majority of records I've read have aligned with what the mom recounts as well. And there are times when mom's memory differs from the chart because the memory was out of context to the whole picture and once it's put into context, the woman's able to revise her knowledge about her own case.

But it can be healing for women to hold their charts in their hands. Empowering, even. So, if you're ready, order your chart, read it and learn what you can about your specific case. Ask questions if you don’t understand something and then move forward with the new knowledge you have about your Self and your baby's birth. As is often said, "Knowledge is Power!"

Me, charting after a birth. Photo by Nova Bella de Lovely.