How and Why You Should Review Your Medical Records

You expect your doctor(s) and their staff to be familiar with your medical history. You probably also assume the information in your records is correct. But your doctor and nurses are only human, and mistakes can happen. Unfortunately, errors on your medical records can be hazardous to your health and even your life, so it’s important to give your records a once-over every so often to ensure accuracy. [1]

According to the Office of the National Coordinator for Health Information Technology, nearly 1 in 10 people who access their records online end up requesting that they are corrected for one reason or another.

An incorrect diagnosis, scan, or lab result can find its way into your medical records, increasing the likelihood of an inappropriate medical evaluation or treatment. Other things, like allergies not being noted or lab tests not being recorded, can also have adverse effects.

Kaiser Health gives the example of Susan Sheridan, a woman who learned this lesson the hard way after her husband, Pat, had surgery to remove a mass in his neck. In Pat’s hospital pathology report, the mass was identified as synovial cell carcinoma, a type of cancer. But that diagnosis never reached Pat’s neurosurgeon, so the neurosurgeon assured Pat that the growth was benign.

In reality, the mass found on Pat’s neck was life-threatening, and when he went back to the hospital 6 months later in distress, that’s when the omission was discovered. By then, his untreated cancer had metastasized to his spinal canal. Two-and-a-half years later, Pat was dead.

Sheridan, director of patient engagement with the Society Society to Improve Diagnosis in Medicine, said:

“I tell people, ‘Collect all your medical records, no matter what’ so you can ask all kinds of questions and be on the alert for errors.”

My Own Experience with Medical Errors

I, too, have had my own experience with potentially-dangerous medical record errors. Just over a year ago, I was diagnosed with uterine cancer. Based on the images my gynecologist sent the hospital where I was being treated, it appeared that I had, and I quote, “a fairly aggressive” form of cancer. But due to my young age and no family history of gynecologic cancer, my oncologist requested the actual slides from my gynecologist. (At that point, they had only included copies of the biopsy results.)

I was extremely fortunate that my cancer turned out not to be cancer at all. Rather, I had precancerous cells in my uterus. I ended up having a partial hysterectomy, but I could have ended up having a full hysterectomy without the full information. And I can’t tell you the emotional stress I was under, thinking I was perhaps on death’s doorstep.

My oncologist had been trying to mentally prepare me for a tough fight. It is not lost on me that had the situation been reversed – if my doctors didn’t think I had cancer at all, but I really did, and if my oncologist hadn’t had the forethought to ask for the actual slides – I could have died at a very young age.

My situation also points to the importance of making sure your family medical history is accurately recorded. Imagine your mother or sister had breast cancer and you find a lump in your breast. If that information isn’t accurately recorded, your doctor could be less inclined to take you seriously, or less inclined to order appropriate tests.

It’s also important to make sure that your name, home address, phone number, and personal contacts are listed in your records. On more than one occasion, a doctor was unable to reach me because the staff failed to update my contact information. Not documenting the correct emergency contacts could prevent your doctor or a hospital from notifying loved ones in an emergency.

How to Check Your Records and Point Out Errors

You have every right to review your medical records, and the law is on your side. The Health Insurance Portability and Accountability Act of 1996 allows you to ask for a correction if you spot an error in your medical records. [2]

Under this law, patients have the right to get some or all of their medical records upon request. If you’re worried about psychotherapy notes, don’t be; these can be excluded.

Hospitals, medical clinics, physician practices, pharmacies, and health insurers are required to make this information available within 30 days (sometimes a 30-day extension can be granted) at a reasonable cost in whatever format the patient chooses, be it a paper copy, fax, electronic copy, or CD.

At the hospital I was treated at, medical records could be immediately obtained in paper form by simply going to the records department, and it didn’t cost me a cent. Within an hour, I had everything I needed.

New guidelines issued by the Office for Civil Rights of the U.S. Department of Health and Human Services in January 2016 prohibit per-page charges and recommend a maximum price tag of $6.50 for patients. The guidelines also clarify patients’ rights to have records sent to 3rd parties, including family members or professionals advocating on their behalf.

The process is remarkably simple. Ask your doctor if he or she has an online portal where you can see and download your health information. If no such portal exists, ask the receptionist for a “Request for Health Information” form. If you need help, talk to the medical records department in your doctor’s office or hospital. [3]

Doctors can only deny your request under 2 conditions:

• They are worried that doing so could endanger your life or physical safety, or someone else’s. [1]

• In cases where facts or medical judgments are in question. For example, if a patient requests that information concerning their excessive opioid use is eliminated, or if a patient wants a diagnosis eliminated. [2]

If a hospital or doctor’s office gives you guff about trying to obtain your medical records, you can download a model of a medical records release form provided by the American Health Information Management Association, which you can bring with you to gently “remind” them of your rights.

Sources:

[1] CNN

[2] Kaiser Health News

[3] GetMyHealthData