Medical records can contain significant discrepancies that may affect patient care, and patients have the right to access their medical records and seek clarification when inconsistencies arise, as demonstrated by a case where conflicting CT scan results and surgical notes raised questions about whether a gallbladder removal surgery actually occurred.
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Video: FOX23 Investigates: Local woman questions if gallbladder surgery happened after conflictingAdded:
A Fox 23 investigation about confusion over a woman's medical records and what actually happened during her surgery.
>> Tulsa's investigative reporter Jenna Clark talked to a woman who wonders if the surgery actually took place. It's her new Fox 23 investigation.
I just don't understand this.
>> Natasha Corey says she started feeling bad about 3 years ago.
>> One day just came on.
>> What were your symptoms?
>> At first I was like just tight underneath my chest area like it just felt like it was like a band just like right there it's just real tight and pulling in large sharp pains. But then later on it just became like burning sensation just got awful pain.
>> You went to the hospital?
>> We had several trips within 6 weeks to the hospital. She went to Bailey Medical Center in Owasso and they referred her to a surgeon at Hillcrest Medical Center in Tulsa.
>> Ultimately what did they suggest?
>> He just said that yeah we can take your gallbladder out. It's probably what it is.
>> Natasha showed me her medical records from Hillcrest. In the surgeon's notes he wrote, "I would recommend removal of gallbladder."
>> You're okay with that?
>> At that point I just wanted out of pain.
>> In the medical record it says that in 2023 Natasha had the procedure. It says gallbladder removed without incident. It goes into detail. The cystic duct and artery were clipped and divided. The clips were then reinspected and found to be intact. Satisfied we proceeded with closure. The patient tolerated the procedure well.
>> From then I came out of that surgery in the worst pain been in pain since.
Nothing's gotten better. After your gallbladder was taken out you didn't feel better?
>> No. I felt worse. I'm still worse. Over the next year Natasha says she went to several doctor visits and eventually headed back to Bailey Medical Center.
They did a CT scan and she saw something strange on the report.
>> got that report and it said gallbladder present.
I'm like well that makes no sense.
>> Here it is in that medical report. Her gallbladder within normal limits.
Natasha says she questioned it.
>> They had another radiologist read my files again and then he amended it.
>> Here it is under addendum showing her medical record was changed. It says the patient contacted the radiology department regarding a gallbladder. The patient has had a previous cholecystectomy. That word means gallbladder removal. It also says although there are no clips visualized on the images. Remember in the original procedure notes, the surgeon had noted the clips were then reinspected and found to be intact.
>> But you don't see clips and usually you have clips, surgical clips put in it with the gallbladder surgery. They didn't see those.
>> The record goes on to say "Review of the images shows no gallbladder present."
>> That's where this paper came from. Bailey Medical Center also sent Natasha this letter that says "We investigated your concerns. The imaging results were inaccurate regarding your gallbladder."
And it explains the addendum to her medical records. Natasha thought that was the end of the issue but still dealt with pain.
>> When I say deal with this cramping in my stomach, I feel like I have sharp pokes in the back of my back.
>> So after that, she went to a different hospital. This time Ascension Saint John Owasso. There she had several more CT scans done. Every scan at Saint John's which has been like three or four has came back gallbladder present. Spoke to the chief of the ER, gallbladder present. Here are Natasha's medical records from Saint John. CT scans from last year show this. The gallbladder appears within normal limits.
Gallbladder and bile ducts, no calcified stone.
>> That says right there again, still have it.
>> And right here it says "Questionable previous cholecystectomy." In his writing, "Questionable." What have they told you in person?
>> One told me that he's puzzled and I'm like you're puzzled, I'm puzzled. Like I had my sister-in-law with me then and she's like, "So she has a gallbladder?"
And he's like, "Yeah, she has one." I looked at him too and asked him to go back and look for the surgical clips.
And he came back in and said no, they weren't there either. I also sent an email with questions. Ascension Saint John called later and asked me to hold the story saying they had updated information but wouldn't give it to me.
They said they would provide the information to Natasha and only through a face-to-face meeting they're trying to set up. I also reached out to Hillcrest and they told me they wouldn't say anything about this except what's already in court records. They're talking about this lawsuit Natasha's attorney filed but later dismissed without prejudice. That means Natasha can still file a lawsuit. In a court filing Hillcrest argued that doctors removed Natasha's gallbladder. Then later a CT scan was initially read by a doctor who noted her gallbladder was within normal limits. But then later after an overread of the CT scan another doctor determined her gallbladder had in fact been removed. Then the doctor amended his initial report.
Natasha showed me how when she tries to find her records online through both hospitals' online portals she's denied access. Won't let me in.
Login failed. Mhm. She told me she's had trouble getting the CT scans, the images themselves. Are you willing to let me be with you with phone calls, let me go with you?
>> no reason not to. Yeah. I sat next to her as Natasha called and asked Saint John for all the images.
>> I'm calling because I need to get some imaging.
>> And I went with her to the hospital to pick up the images. Inside she asked for clarification about her records. She didn't get answers that day. Someone told her a doctor would call her. Once we got the CD I sent all the images to an independent surgeon to review. He said he was not able to say anything about the gallbladder based on the number of images. These were only a few selected images, but he did say Natasha's medical report says there is a gallbladder. Now, Natasha just wants answers to clear up all the confusion.
But I still shouldn't get told you have a gallbladder still and these records over here from my surgery saying it's being removed.
In no time should anybody have to go through that. So, as we're sitting here right now, you don't know whether you have a gallbladder or not.
>> I I don't know. I haven't known for 3 years. What do you want out of this? I just want somebody not to have to go through what I'm going through. I want somebody not to ever have to doubt for 3 years in their records that you had surgery and then oh, you still have this organ. I just want to know if I have a gallbladder or if I don't. What can I do to stop the pain that I have?
>> Covering news that matters, Jana Clark, Fox 23 News.
Natasha told Jana she called back again and asked Ascension St. John again for all the images from her CT scans. She says she also got a call from Ascension St. John and they told her they want to have a formal meeting with her.
Ascension St. John sent us a statement that says, quote, we take concerns regarding patient care seriously and are completing a thorough review of this matter along with our diagnostic radiology providers. Once complete, we will evaluate any appropriate actions identified.
Do you have a tip or issue that you think Jana Clark should investigate? Let us know. Email [email protected] or call 918-388-5354 or search Fox 23 Jana Clark on Facebook.
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