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CamilleRN
CamilleRN, Nurse (RN)
Category: Health
Satisfied Customers: 4183
Experience:  Experience: 20 yrs experience in ER, ICU, Neuro, OR, Chemo,Cardiology, Dermatology and MORE.
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A friend of mine was in the emergency room and some of the

Customer Question

A friend of mine was in the emergency room and some of the stuff they put on this person record as her not experiencing on what I guess you call a check list they put no down was actually as yes. She also told them yes will she was their and want this to reflect in the records. Is there a way as this can be add as a patient statement or something? Also who should she take this up with title wise to make sure approximately taken care of? Also what is the approx process taken by this person once made aware of this?
Submitted: 6 years ago.
Category: Health
Expert:  CamilleRN replied 6 years ago.
CamilleRN :

Welcome to JustAnswer Health...and thank you for your question. I am a verified Expert and am delighted to help you today. She needs to see the Director of the Emergency room or his/her assistant so that the medical record can reflect the true picture of what was going on at the time. An addendum can be written and added to the chart.

Customer:

Is there a time limit on this because the person been out the hospital for over 1month . Was limited to getting the record untill recently because heart condition and also they still took about two weeks or so for them to finally give her the records. Also what is patient relation real used for? Also what do no tracheal deviation present and no thyromegaly mean? Also what do minimal left basilar atelectasis mean?

CamilleRN :

Also what do no tracheal deviation present ( THIS MEANS THE TRACHEA IS IN THE NORMAL POSITION) and no thyromegaly mean ( THIS MEANS THE THYROID IS NORMAL IN SIZE) ? Also what do minimal left basilar atelectasis mean?( THIS MEANS THAT A SMALL AREA OF THE LUNG WAS NOT EXCHANGING GASSES PROPERLY)

CamilleRN :

ALl he can do is ask to add an addendum to the record

Customer:

Is there any reason for for them not to make a addendum to the record or is it done with no problems? How long do getting changes made usually take or would this be something you know or not know? I'm just trying to help her along and be the best friend I can be. because the way I see it the more informed picture they have the better is her treatment for all condition with further doctor wither emergency room or other physican..

CamilleRN :

Different hospitals have different policies. I am not aware of a time limit for adding information to a patient's record that will be helpful for future care, however, the addendum will not strike out any information that is already there, but rather it will serve to supplement it.

Customer:

who in the hospital be able to give you there policies on such a matter?

CamilleRN :

Hospital Administration