Statements in the medical records are not admissible evidence. They are hearsay. Don't get hung up on the statements in the medical records. Instead, have your attorney take deposition of the doctor and get the doctor to admit that the statements are in error or are without foundation. Such admission will be evidence. If there is no lawsuit pending, you still may be able to obtain an affidavit or declaration from the doctor. Good luck.
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I am sorry that this statement has impacted your family. However the testing puts that issue to rest completely. Doctors are required to develop a differential diagnosis which is speculative. They develop a list of potential causes for what they observe clinically. Then they eliminate the likely and most harmful causes through testing u til a diagnosis is reached.
No and No. First of all, your sister's medical records are private. Without a HIPAA release that she has to sign ,no one else sees them. From a damage perspective, no one other than a healthcare provider who needs records to treat her, or your sister, will see. Ms Herd is right. When your sister came in, and because of her stoke was incoherent, drugs, and/or a drug reaction would and could be part of their differential diagnosis. Obviously they diagnosed her correctly with a stroke, so the discharge diagnosis would be a stroke. Focus on helping your sister get better, you should not stress, worry, or bother suing over the medical records issue.
You sister has a right under federal and California law to ask for an amendment of her record. The hospital will have a process for considering her request - the medical records department is the best place to start. The hospital and the doctor that made the statements you disagree with do not need to agree to change them, but your sister at a minimum has the right to insert in her record a statement of what she disagrees with what's there. I'm including links below to the Medical Board of California's information about this and a hand out from the federal Office for Civil Rights.
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