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We see medical records all the time. It’s not unusual to find mistakes or items that are left out. Sometimes, the omissions are fatal. Other times, they are never to be thought of again. Talk to the client after and you will hear, "the doctor was in a rush", "didn’t seem to be listening", or "was thinking about some other issue". There are even groups who simply keep themselves out of issues from a motor vehicle collision, by just not documenting it. The person isn’t there for the collision, so let it be someone else’s problems.

Seems to me that leaving things out for your own purposes does more harm than any gain that the doctor may perceive. A history should be a history.

Recently, i ran across some helpful hints from Medicine Plus on how to make your medical visits more successful:

Here are some things you can bring to make the most of your visit:

  • Lists of your concerns, any allergies and all the medicines, herbs or vitamins you take

  • A description of symptoms – when they started, what makes them better

  • A notepad or tape recorder

You are there for a reason. It’s important that you be heard and get the right information out. It also is important for you that the records always be accurate.

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