9 Investigates

Incomplete medical records causing problems for NC patients, doctors

CHARLOTTE, NC — Deborah Pittman struggles to brush her hair because of continuous pain in her left hand.

She blames a 2016 trip to Caromont Regional Medical Center in Gastonia where she received a CT scan because of respiratory problems.

"Since that day my life has changed drastically," said Pittman.  "It affects me emotionally and physically."

Pittman claims staff inappropriately administered contrast fluid through an IV in her hand.

"It was burning. I mean excruciating, burning," she said.

Pittman said a picture she took that day shows where staff tried to move the IV, attempting a second stick in her arm before a third successful IV near her elbow.

When pain in her hand persisted, Pittman requested her records, trying to get treatment covered but she said her nearly 400 pages of records mention only one IV.

Caromont Regional Medical officials told Eyewitness News they investigate all patient complaints and grievances, but they cited patient confidentiality, and wouldn't comment on Pittman's claims.

Caromont said, "We have many procedures and protocols in place to ensure and support that safety, including the active monitoring and investigation of all safety-related activities and concerns."

Eyewitness News learned the issue of incomplete medical records has gotten the attention of the North Carolina Medical Board.

Officials said in cases where they take disciplinary action against doctors, they find record keeping is a problem 25 percent of the time.

Dr. Karen Burke-Haynes, the board's Chief Medical Officer, said the board closely examines what doctors put in patient charts.

"If it lacks detail, if it's inaccurate information, absolutely it can be harmful," said Burke-Haynes.

The board updated its policy this past summer, alerting doctors of the expectations.

One concern is that some doctors may rely too much on electronic software.

Doctor Babak Mokari showed Channel 9 how the convenience of electronic records could create problems if doctors don't add specific details.

"Otherwise, every visit is going to look the same and it is going to seem like the interactions are all sort of generic," said Dr. Mokari.

Pittman said she never received an explanation for the missing information but she hopes her story is a lesson to other patients.

"You need to pay attention to this stuff and always question, 'Did you put that in my chart?'," said Pittman.

The Medical Board recommends patients should ask for a summary of care after every appointment and if their provider offers an online patient portal, use it to access some records and test results.

If patients disagree with information in their chart, they have the right to right ask that an amendment with their point of view be included in their file.