Falsified Medical Record

I'm really irked right now with humanity.  Namely so-called medical professionals.  This morning Lisa took me to an eye appointment.  It's been almost 4 years since I've had a diabetic eye exam and I need a new prescription for eyeglasses.  I called around to many optician offices and no one will see me because they claim they can't accommodate my wheelchair and my not being able to be transferred.  

So I made an appointment with Cascade eye and skin – which is the place I went to only a few days before dad died– which was my last eye exam.  I remember it well.  They were able to treat me then and gave me my exam.  So, even though they no longer take my insurance, I was willing to pay out of pocket to go back to get my eye exam.

Well, to make a long story short, they wouldn't treat me because I can't wear a mask.  I explained that I can't drive my wheelchair with the mask on.  So they told me I had to wear a mask while I'm sitting there.  I told them I have a hard time breathing because I only have use of my diaphragm and not intercostal or abdominal muscles to assist me in breathing.  (I was already having a hard time breathing today). They didn't care.  They wanted to murder me by suffocation.  So,I told her I can't and we will just have to leave.  So, we just left the waiting room and came home.

But, that's not what this blog is about.  Although, coincidentally, it's in the same office building as the gastroenterology appointment I had which is what this blog is about.

I had a useless gastroenterology follow-up on Monday.  The PA – Shayla Fawcett – diagnosed me with and treated me empirically for small intestinal bacterial overgrowth (SIBO) on December 16, 2022. Which incidentally the treatment was antibiotics (Augmentin) which made my condition much worse.  So it turns out, that the diagnosis of SIBO was wrong. And I'm still suffering the repercussions of that misdiagnosis every day since I took the antibiotics in January.

Okay, so fine, there's nothing they can do to help me.  I had zero intention of going back for another useless follow-up.  Which I told the scheduler when she called to schedule another follow-up.  But what irks me is the falsifications on my soap notes (medical records).

The funny thing is, I probably never would've even seen the soap note from my March 13, 2023 follow-up if they hadn't sent me an email telling me I had a message to read.  So I logged onto my gastroenterology my chart and read my soap note.

Then I got mad because it was full of lies.

There was no physical exam performed.  There was no breath test for SIBO performed ever.  And, she did not discuss with me any risk factors for metoclopramide except tardive dyskinesia.  Even after I specifically asked her for other risk factors.

Here are the excerpts from my soap note and my communication with their office via my patient portal messaging system on their website.

To Practice: Patient Portal Manager
From Patient: Tamara Stone (DOB:***)
Sent Date: 3/15/2023 9:24:12 AM
Location: WAGI (Washington Gastroenterology)
Type: Clinical
Subject: soap note
​ ​
I have a problem with the soap note that Shayla wrote for my follow-up on March 13, 2023. ​ ​In the note it states that a breath test was done for sibo which came back negative. ​ ​No such test was done.
​ ​
It also states that a physical exam was performed. ​ ​She did not perform a physical exam on me. ​ ​She did not come close enough to look at me let alone touch me to perform a physical exam. ​ ​It also states ambulatory under physical exam. ​ ​Which is incorrect. ​ ​
​ ​
And, the note also states that risk factors for metoclopramide were discussed. ​ ​The only risk factor she mentioned was tardive dyskinesia. ​ ​Even after I specifically asked her what the other risk factors were, she reiterated just tardive dyskinesia. ​ ​So the other risk factors mentioned in the soap note were never discussed during my visit.
​ ​
I am not happy with these falsifications in my medical records.
​ ​
Sincerely,
​ ​
Tammy Stone
​ ​
This was the reply I got:

--------------------
To Patient: Tamara Stone (DOB: ***)
From Practice: Brittany B. (DH) Clinic Manager - PUY, SUN
Sent Date: 3/15/2023 11:33:53 AM
Location: WAGI (Washington Gastroenterology)
Type: Clinical
Subject: Re: soap note
​ ​
I sincerely apologize for the mistyped portions of the visit. To clarify regarding the concerns:
The physical exam documented is all visual and based on communication (no abdominal exam was done this visit or documented, nor were other portions that required me to touch the patient). ​ ​I did by mistake document ambulatory in the initial functional/cognitive portion, however in the musculoskeletal portion it is accurately documented that she is in a wheelchair and has quadriplegia.
The mistyped ambulatory portion was corrected in an addendum. I also corrected the mistyped portion in the diagnosis comments regarding Breath Test for SIBO. She was treated empirically for SIBO at previous visit rather than order Breath Test at that time, as I discussed with her in clinic SIBO less likely as she did not respond well to empiric treatment with Augmentin. We did discuss tardive dyskinesia as the primary risk/concern with increased/long term Reglan use (risk of tardive dyskinesia increases with long
term use and higher dosage), but I wanted to provide you with further information on the handout as you had asked those questions.
Shayla Fawcett PA-C
​ ​
There was an addendum done to the visit notes to correct the mistakes. We are so sorry for the errors and thank you for bringing this to our attention. I will publish that to your patient portal. Please let me know if we can be of any further assistance.
Thank you,
​ ​
Sincerely,
Brittany ​ ​
Clinic Manager
--------------------

This was the addendum (notice that it was not signed):
​ ​

This was my reply:

To: Patient Portal Manager
03/15/2023 12:22 PM
Subject: Re: soap note
Location: Washington Gastroenterology
Type: Clinical
I appreciate the addendum but it's still not correct. ​ ​The soap note clearly states that the negative breath test for SIBO was on that visit – March 13, 2023 – not the prior visit in December. ​ ​The addendum only mentions not doing the breath test in December.
​ ​
Also, I never received any handout at the visit, nor afterwards. ​ ​The only information I got regarding risk factors for metoclopramide are on the soap note which specifies that we discussed multiple risk factors during the visit. ​ ​The only risk factor discussed during the visit was tardive dyskinesia.
​ ​
Please fix the addendum so that it is accurate.
​ ​
Thank you,
Tammy Stone

I got no reply.  I sent another message a couple of hours ago asking for a signed addendum with the correct information.  As of right now, no reply.

Okay first of all, as to the physical exam.  She stated that it was all visual and verbal. Isn't that what a history is?  That's the history part of the history and physical. Not the physical.  How is a physical exam visual (from 5 feet away) and verbal?

Secondly, she stated that nothing was documented that she couldn't visually assess.  How could she see that my sclera wasn't jaundiced or that my conjunctiva was pink or that my pupils were equal from 5 feet away?  And how could she tell that my neck was supple and there were no masses and that my trachea was midline from 5 feet away?  But that's not even what irked me.

She specifically stated that she performed a breath test for SIBO which came back negative.  Blatant lie.  No such test was performed in either of my visits in December 2022 or March 2023.  And another blatant lie was that she discussed the risks of metoclopramide with me.  She did tell me about tardive dyskinesia.  And I asked what some of the other risk factors were and she said that was basically it, just tardive dyskinesia.  Then in the note she lists all the other risk factors that she said she discussed with me.  Then, in the addendum she has the audacity to state that she gave me a hand out of the risk factors.  Blatant lie.  I was not given any handout regarding metoclopramide risk factors at the visit, nor afterwards in my patient portal documents.

And, if you notice she didn't even sign the addendum.  So, it's not even recorded.  She just sent it to me to appease me.  And it wasn't even correct!

I'm fine with people making mistakes.  Mistyping something or even overlooking something that's automatically entered and not fixing it are excusable mistakes.  What I'm not okay with are blatant lies.

Stating that you performed a breath test – which was never administered – is a blatant lie.  Or stating that you discussed a multitude of risk factors and listing them individually– which only one was discussed – is a blatant lie.  Then stating in the addendum that a handout of said risk factors was given to me–when no such handout was given at the visit nor afterwards – is a blatant lie.

Why lie on medical records?  If you wanted to say that I had a negative breath test, then why didn't you perform one?  If you want to say you discussed risk factors for metoclopramide with me then why did you only mentioned one during our visit, even after being asked specifically what the other risk factors would be?  Because she didn't know any others.  That's why.  She had to look it up and then put it in the soap note as if she discussed it with me.  Then when I called her out on it, she claims she gave me a hand out of the risk factors, when she didn't.  Blatant lie.  And if you want to claim you did a physical exam, could you not at least feel the neck and look in the eyes?

I despise dishonesty.  And it appears as though she's not going to fix the addendum nor sign it.

Word to the wise – do not do business with Shayla Fawcett (physician assistant) at Washington gastroenterology.  She's a terrible medical provider who lies on medical records. These were not simple mistakes.  And whose misdiagnosis caused me to be much worse off than if I had never been treated by her.  And I sure wish I hadn't been..

Also, do not do business with Cascade Eye and Skin at the same Sunrise location in Puyallup Washington.  They are tyrants who discriminate against handicapped people.

That's my two cents.