Wondering what to do before consulting an attorney for the following situation. Woman goes to a medical specialist (first visit) with a serious, painful and rare condition in an embarrassing area of the body. During the evaluation the woman gives a full case history and discloses a condition that is relevant to her present problem. Woman says "I am telling you this but don't write it down as I do not want it on my medical record." Medical practitioner does not say anything along the lines of "I must write it down since you told me" or even "Don't worry, I won't write it down." Treatment given doesn't improve condition. Woman hears of another doctor who specializes specifically in the condition that she thinks she has. Woman signs a release giving first doctor permission to send her medical records to second doctor. The cover letter has woman's fax number. The release has the fax number of the doctor to receive the records. Nothing happens as new doctor has not received records. Two days later woman again calls up to find out where the delay is and sends another letter requesting her records to go to second specialist. This time she sends the cover letter from work. Next day woman finds three pages in her inbox at work. The doctor's office faxed the sensitive records complete with diagrams and detailed medical history including the condition that she specifically requested not be put in writing.
About the mistake of sending the fax to the wrong place the doctor's office apologizes: "It's never happened before". Woman did not realize until later about the additional condition being put in writing. Meanwhile woman is not sure who saw this sensitive data and if any of it was shared with other co-workers.
Woman is not going to lose her job based on what was revealed, but she is extremely uncomforable about who knows what about her private business. Also, if woman sues how likely is that to affect her receiving medical care in the future? Any comments aside from consult an attorney and report this to the state board and HIPPA?

Mistakes like this do happen, unfortunately.

I would like to focus, though, on the "additional condition."

It is necessary for us to chart the "additional condition" to make sure that all bases are covered when it comes down to treatment options.

For example... I work in Labor and Delivery. If I did not chart that a woman told me that she had a STD because she did not want anyone to know and that she wanted to keep it private, I would be doing the baby that I will be delivering an injustice as that STD could seriously harm the infant.

All medical/health information is pertinent to the treating MD.

Now, back to the fax. She can report this to the governing board of the medical provider who sent the fax in error, i.e. the office manager (as it was most likely a nurse or receptionist/secretary wo faxed the info). Steps should be taken to discuss this with the employee to prevent future errors such as this.

J_9's response just about covered it, IMO. I don't see suing anyone because, for one thing, there were no damages other than being "extremelly uncomfortable" about the inadvertent disclosure of information. That doesn't translate into dollars and cents very well at all.

Thank you both for your input, especially regarding whether a lawsuit is called for. I appreciate your opinions.

I would like to clarify my thoughts on the "additional condition." 1. It is not something that poses a danger to anyone, such as witholding information on an STD would do. 2. The provider could have described the condition without labeling it, which would have been truthful and more acceptable. 3. If the provider felt it was absolutely necessary to document using the word that the woman requested not be put into the medical record, is is not reasonable to expect that the professional thing to do would be to say so and give her reasons for the necessity? The woman believes it would have been more acceptable to have an honest discussion, rather than the provider remaining silent (if indeed she was paying enough attention to notice that the patient made that request). The result is that trust in the patient/doctor relationship has been badly damaged.

J_9, If you were the provider in a similar situation, would you feel it imperative to respond to your patient when she requests something that you know you will not comply with? Or would you let the moment pass without comment?

If the other condition was mentioned by the patient it is written down, ** period** her request not to, is ignored and has no real bearing, they are required to write it down, and did not wish to argue with patient about having to.

So there is no legal action what so ever that is available for the medical staff doing their job. In fact there could be a law suit for them not writing it down, and it turned out to be serious enough latter to effect case.

As for as the fax, yes mistakes do happen, someone hits a wrong number and it goes to even a non related third party.

The most you will get would be the people involved take a class on proper fax use, and a written "I am sorry" from them, at best,

There is no case what so ever that I see.

And yes, we get told "private things" all the time, and if they are part of what we are looking at, it gets put into the record. No matter what the patient asks, if the patient does not want it in the record, they should not tell us.

So it works like this, don't write this down, they say,but I have to, the other person gets angry, and before long, we call a supervisor in, and waste 20 minutes.

No we write it down, ignore their request and go on with our day.

Not only is there nothing actionable here but there is not even a HIPAA violation.

There is a reason a medical history is taken. A doctor needs to know any pertinent medical history. If a doctor made a mistake because a medical history was not complete the person taking the history would be liable. Yes it would have been a good idea for the person taking the history to say; "I'm sorry but its necessary to document your history" But its not required.

As for the fax #, it depends whether it was clear to the person sending the fax that this was not a personal, insecure #. If the # was listed as part of the patient's record, there may have been no way of knowing the nature of the #.

Personally, I don't think you understand how practicing medicine works. That's not a slap in the face to you, but reality.

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The provider could have described the condition without labeling it,

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This is not something we can do in all honesty. All conditions have a label and, as such, becomes part of the medical record. While you, as a supposed outsider, don't understand how this works. All medical conditions can be related and have to be labeled accordingly.

While one medical condition may have one or two treatments, it can intertwine with other medical conditions and treatment has to be appropriate.

For me to treat a patient, I have to know the ENTIRE background. I'll give you another example. If I have a patient with high blood pressure, I have to be careful what I prescribe for allergies as allergy medication can exacerbate high blood pressure.

Another example... If I have a patient who is on methodone treatment for drug addiction, I cannot prescribe phenergan for nausea and vomiting because the interaction between the two can cause psychosis.

So, you can see that knowing the entire medical background is a necessity to help the patient.

I'm not going to rehash the fax incident because accidents happen and HIPAA allows for situations like this.

If you could provide more information it would greatly help me to help you.

Also even actions in a office, ( or in my case when I do home evals get written down.) If your speech is slurred, or perhaps have trouble using one arm or other is all noted at times.