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  1. #1
    Join Date
    Nov 2010
    Posts
    3

    Default Medical Records

    My question involves medical malpractice in the state of: Massachusetts
    Along with a slew of other mishaps, I was wondering if a doctor must list all medications that were administered while at the hospital on the medical records? I picked up my records today, and was confused that the two drugs, oxytocin (which I implicitly had said I did not want for I wanted a natural child birth) and the delauded--spelling?, that I was given were not listed on the records. Actually, when it asks on the record if iv fluids were given it states, "0 cc" I was just pondering on whether or not this disclusion is legal. Since my mother is in the medical field, she had informed me that every drug that is given must be on the medical record for fear of an adverse reaction. I need to know whether there is truth to this affirmation. Any questions please ask.

  2. #2
    Join Date
    Oct 2006
    Location
    supratentorial region
    Posts
    818

    Default Re: Medical Records

    All medications given are to be documented in the medical record.

    I cannot imagine you were given Dilauded during labor.

  3. #3
    Join Date
    Nov 2010
    Posts
    3

    Default Re: Medical Records

    Oh, I wasn't just given it once, but twice, and practically after the delivery was over because it required some signatures. So after this horror show was finished, I was so out of it that I told my husband,"thank god it was all a dream." I researched dilauded, and it said it is primarily given to cancer patients or in pallative care. I did not ask for this drug, and knew nothing about it. It was administered through my iv..they asked me if I wanted an epidural, I declined, and was also asked if it was alright if they put me under general anesthesia which I also dismissed. I asked for something to take the edge off. In addition to all this, the iv that they said they were giving me when I first arrived was fluids so that I wouldn't get dehydrated when I got home I researched 'oxytocin' which is uterine contractor. I was 23 weeks, and they did nothing to stop the resident doctors decided to accelerate it. My water had not broken before they gave me this drug, and I asked if there was anything to stop the contractions, and the doctors said, no, theres nothing. I was 4cm, still at the point where an emergency cerclage could be done. I also told them when i trusted this was my only option that I wanted a natural birth without anything to progress labor. I was in no danger, baby's hb was 179, and there was no infection. My baby was born alive, but was two days short of when the doctors intervene by cpap. Now, my records state I received nothing. I have witnesses that I received an iv, and dilauded. This is simply beyond my belief; it's like a movie. Oh, and the week before the sonographer had said my cervix is shortnening and looked like it was starting to open and reassured me the doctor would be doing a transvaginal ultrasound, but he never did. He said it looks ok. A week later, incompetent cervix.

  4. #4
    Join Date
    Oct 2006
    Location
    supratentorial region
    Posts
    818

    Default Re: Medical Records

    I was 23 weeks, and they did nothing to stop the resident doctors decided to accelerate it.
    I am sorry for your loss.

    You did not indicate you were delivering at 23 weeks in your first post.

    Regardless....all medications will be listed in the medical record.

    I have to ask...why are you so sure you were given the medications?

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