Setting the record straight
When I was about to be discharged from the hospital, the doctor on duty came by to go over my discharge information and see if I needed anything. While she was there, I asked if I could have a copy of all the medical records from my stay in the hospital. She thought for a moment and said, “well we normally only give those to other doctors, but it’s totally within your rights to have. We just don’t get anyone asking for them.” I told her that I know it was a bit of a weird request and she just smiled and said, “yeah, but you’re a little weird.” I took it as a compliment.
So I went back to the hospital today to sign for my medical records and drop off a few much-deserved thank you cards. My OB Dr. D had unfortunately gone home early after pulling an all nighter the night before so I missed her, but was able to chat with a few of the nurses and promised to bring the boy back for another visit next week. My fetal diagnostic nurse was there and super excited to see our beautiful son. And I was able to get to the front desk of the maternity ward to deliver thank you cards to my delivering doctor and nurse which they hopefully will receive this evening when they get to work (more soon on all they did to deserve those as I chronicle this birth).
After getting fussed at by the woman at “Patient Information Services” (that’s what they call the medical records department now) for bringing the boy with me to the hospital while she has a cold, she did print out a copy of all my records from my stay. For being such a thick packet of paper it is surprisingly sparse on the details of my birth experience. I did find out I was officially on an epidural from 23:35 Wednesday night to 06:44 Thursday morning, but nothing says what the dosages were during that time and I know for a fact they turned it off around 3am. I had to Google what it meant for me to have macrosomia since it sounded serious – apparently that’s medicalese for “big baby”. Other notes include:
“Patient requests natural TOL (trial of labor?) despite Bishop score of 2 and fetal macrosomia. Patient preference is no Pitocin, saline lock on the IV, doula in the room, and not to remain in bed during trial of labor. Patient has been offered a C/S (c-section?) in the past and today, but requests TOL prior to C/S.”
I also learned that I had “bilateral 2nd degree sulcal tears repaired with 2.0 vicryl” which translates to “shredded crotch”, but it doesn’t detail all the lengths and care the doctor went to putting me back together.
The records told me that Ian’s Apgar score was 5 at one minute and 7 at five minutes, something no one told me while we were there.
What’s odd is that nothing says what time I was given Pitocin and what the increments were changed to over the evening. I’m not sure if this is because they didn’t give me all the records or if they literally don’t log all that. I lean towards the latter since it says I only had 30mL of mineral oil and I know for a fact they must have dumped at least a gallon on me to keep me from tearing more than I did.
All of this goes to show that if you want to know what happens to you when you’re at the hospital, it’s up to you to log it yourself. I look forward to reading the notes our doula took for us as she wrote down the name of every doctor and nurse we spoke to as well as all the medications I was given and when. It was still very worthwhile to get all the records, but they certainly only tell part of the story. I’ll be curious to see if there are more details somewhere else that my OB will have when I see her in a few weeks.
Eventually I hope I can give you the inside scoop on why or how things get documented. For now, I dunno! If I ever do this though, you can bet I’m getting a doula after everyone’s positive experiences with them. Unless I am like “see you guys at 6am on blahblah for the C/S”.
I was leaving you a message and the darn thing went weird.
From what I know (based on five years of reading medical records and working in a hospital with medical records here in Virginia); there is a record of everything that happened during the birth of your son. Thanks to lawyers and birth injury lawsuits there is a record of the drugs you were given and when. There are physician notes as well as Nurses notes. The reason they’re not in the file (and it’s not complete) could be that they’re still being transcribed (especially if the hospital uses a transcription service). Sometimes it can take a while for all of the notes to end up in the medical record.
I can tell you from my rescue squad days that an APGAR of 5 is good for a newborn. Taking the APGAR score at birth and 5 minutes later is something pretty reasonable, and they hope that the score will go up at the 5 minute mark.
I also know that lots of people aren’t interested in the actual numbers, at that point, and they’re more focused on other things
I’ll shut up now
You’ve made me very curious about my medical records from birth – we reconstructed our timeline from twitter, it’d be kinda neat to see what the records say.
I’m still in awe of you and very much look forward to reading your birth story.
I also find it fascinating that the medical records call it the “trial of labor” – such an interesting phrase.
Trial: a test of faith, patience, or stamina through subjection to suffering or temptation;
Certainly not wrong, just not how I expected it to be referenced in medical charts.
As the director of a Patient Information Services (medical records!) Department at my company, I can tell you that medical professionals vary widely in their ability to accurately reflect what happens. Everything is documented, particularly with respect to medication dosages, they are often written on a separate chart or graph, not always in the physician’s notes. They definitely noted the time of things, and the dosages — it is required. Why does it matter now, though?
Jennifer C. Reply:
November 3rd, 2009 at 11:37 am
Because Genie is just a teensy-weensy bit anal
I’m sort of curious about my own records now.
Christine B (Leofwynne) Reply:
November 3rd, 2009 at 2:31 pm
Well, I know she is a teeny bit anal, but I guess my question is more along the lines of “what is to be gained by having this knowledge now? Baby’s born — safely and healthy, GA is fine and recovering, all is well.” You can drive yourself crazy with information.
Genie Reply:
November 3rd, 2009 at 3:23 pm
Mostly I want to solidify all those fuzzy memories I have of things. If I know I can push a kid out on 12 milliunits of Pitocin and no epidural it may be handy info to have when it comes time to try this again. Also no one told me things like Ian’s Apgar or his blood type or what all his blood glucose readings were in the nursery and from a medical curiosity standpoint I like to know.
I don’t plan on suing anyone about anything or second guessing any decisions, I just want to have a clear record of it. It’s the historian in me.
Christine B (Leofwynne) Reply:
November 3rd, 2009 at 3:56 pm
And you’re right, it may be helpful info, down the road, although NONE of my three labors and deliveries were at all alike, except that I had all 3 in a hospital.
Huh. I don’t know my kids’ blood types off the top of my head…probably should.