"Inaccuracies in paperwork related to recent ED presentation"

I arrived at ED via ambulance following an episode of swelling of my soft palate, this is the second time this has happened. I was treated with respect and dignity in the ED and short stay unit.

I had a GP appointment the day after my ED presentation. As a health professional I checked my discharge summary to ensure my GP would have all relevant information. I noticed 2 errors: 

- As well as suggesting that GP follow up pathology results, which was correct, it also suggested that there be further neurological investigations - I did not have any neurological symptoms during my ED presentation.

- Medication section of discharge summary the word nil was written. I knew I had been given 1 tablet and IV medication via a syringe driver during my ED admission; I specifically remembered the syringe driver, as I had to hold it at one stage and the attending doctor removed it from the IV cannula, once dose the does was administered, to take my blood tests. 

I phoned the hospital to clarify the medication I was given and the dose. I was told that I was in error about the IV medication and that I had been given 2 oral medications - loratadine and dexamethasone - I asked, What doses? The reply was ,The usual dose. I found this response unsatisfactory.

The following day I phoned Bass Coast Health medical records and asked that all paperwork relating to my recent ED presentation be faxed to my GP. This was done in a timely fashion and my GP had received the information prior to my appointment.

My GP asked if I had any neurological symptoms - No.

My GP checked the medication chart - it listed the P/O (oral) loratadine and  P/O (oral) dexamethasone 8mg in 2mL (indicating it was an injectable medication - either IV or IMI) the chart also documented an IV flush, again suggesting medication given was IV rather than intramuscular injection (IMI) or P/O. My GP stated he had no doubt that I had been given IV dexamethasone due to my recollection of events and the anomaly in the medication chart i.e. dosage expressed in mg/mL and IV flush given.

As my condition is still under investigation it is vitally important that all documentation relating to my symptoms and my treatment is accurate.