Are your medical records accurate? Probably not! Unfortunately, your health records likely include mistakes about some aspect of your health and/or your medical and family history. Whether your doctors use Electronic Health Records (EHRs) or paper records, the risk for mistakes is real.
Certainly, accurate medical records are essential for receiving the best healthcare possible. How can a doctor treat appropriately if your records contain wrong or incomplete information?
What kinds of mistakes are we talking about?
It is possible for any item in your medical chart to be wrong, including information on diagnoses, tests, treatments, medications, family history, and allergies.
Importantly, mistakes can occur in records kept by individual doctors, large group practices and hospitals. And, as mentioned, above, both paper and electronic records can contain mistakes.
And these mistakes can follow you for years – as one doctor after another includes the same erroneous information in your records.
NOTE: In this post, the term “provider” includes all medical professionals as well as hospitals.
How often are medical records wrong?
Many experts think errors in medical records are widespread.
For instance, Dr. Heather Gantzer, past chair of the American College of Physicians’ Board of Regents, states that “One-hundred percent of medical records have errors. Some of them are nuisances, but some are really impactful and might make a huge difference for the person…”.
Additionally, a study published in 2020, compared 105 appointment notes to secret audio recordings of each appointment to identify discrepancies.
For the 105 appointments, they found 636 documentation errors — 181 findings included in the record that did not take place, and 455 findings that should have been documented but were not. Importantly, 90% of the notes contained at least 1 error.
Additionally, in 21 instances, the doctor’s note justified a higher billing level than the “gold standard” for the actual care delivered.
Patients find errors in their own records.
A survey study, published in 2020, asked patients to review their electronic health records for accuracy. Of those who responded to the survey, 21% saw a mistake in their record. Furthermore, of those who noticed a mistake, 42% thought the error was serious.
In this survey, the errors noticed included wrong body part, wrong side, reason for visit omitted, wrong patient, missed history of anaphylaxis, and a reference to a female’s left testicle.
Finally, another study, published in 2019, asked patients and families to report mistakes they found in their electronic records. Overall, 27% of participants found a “potential inaccuracy” in their records. Moreover, among the mistakes identified, 58% of the records contained mistakes identified by the patients and families as either important or very important.
Most of the potential inaccuracies were related to incorrect descriptions of symptoms and/or past medical problems. Additionally, some found incorrect medication lists or missing information.
How do mistakes in medical records happen?
In a nutshell, most mistakes come from human errors or electronic systems design flaws.
All people make mistakes, including healthcare providers. For starters, doctors and medical staff are stressed and burned out. Additionally, appointments are often rushed, leading many doctors to skip the documentation process during an appointment. Instead, they may document each patient visit after hours or even on another day. Certainly, in these circumstances, it’s easy to see how doctors can make mistakes.
Your doctor may make documentation errors by:
- Entering incorrect information or leaving something out.
- Confusing you and/or your history with another patient.
- Accidentally transposing numbers on a diagnostic code or test result.
- Misunderstanding what you say and then entering incorrect information.
Additionally, medical record errors can occur if you forget to tell your doctor about an issue, like a new symptom, medication, or allergy.
Copying and pasting data.
Certainly, if a previous record contains an error, the error will continue to appear if medical providers copy the data from one visit and paste it into the record for the current visit. Unfortunately, copying and pasting is common, and often occurs without checking if the information is accurate.
Importantly, one study, published in 2022, analyzed 100 million clinical notes across all medical specialties over the course of 6 years. The analysis found that 50.1% of total clinical text was duplicated from previous text written about the same patient. Surprisingly, further analysis showed that 54.1% of duplicate text came from a previous note by the same author (or earlier in the same note), but 45.9% came from a note by a different author.
EHR design flaws.
EHRs come with their own set of pitfalls for errors. According to an article in Medical Economics, EHR technical issues can lead to errors.
Specifically, many EHRs aren’t very user-friendly, making it hard for doctors and others to navigate the system and correctly add information.
Moreover, many EHRs use auto-complete software, which automatically fills in text after doctors type a few letters. But the software doesn’t always guess right! If the doctor doesn’t notice a mistake in the auto-fill, the software leads a doctor to accidentally enter incorrect information.
Additionally, the auto-correct function can cause havoc. Auto-correct identifies and corrects spelling errors, but it can also change words to other, similar words that are incorrect for a specific patient.
For information, read 6 Dangers of Electronic Health Records.
How can medical record errors impact patient care and health?
The possible scenarios range from annoying to outright dangerous. It can be annoying when you must repeatedly correct the list of medications your doctor has in your record. But it can be life threatening if your record contains errors in diagnosis, treatments, or medication allergies.
There are endless possible scenarios in which inaccurate medical records could cause you harm. Consider these few examples:
- You are in the ER and are too sick or injured to communicate, forcing the staff to rely solely on your medical record, even if it contains mistakes.
- One doctor doesn’t know you full list of medications, and then prescribes a medication that can dangerously interact with a medication you already take.
- Your records exclude important family history, which can lead a doctor overlook an important possible diagnosis.
- You can receive treatments for a condition you don’t even have!
It’s easy to see the potential for huge problems if doctors rely on incorrect medical information.
Importantly, if you don’t notify your doctor or hospital about mistakes you find, these mistakes may follow you for years and years.
Medical record errors can lead to billing errors.
Your record might state you received a test or treatment that you never had, which can lead to erroneous bills.
How do you make sure your medical records are accurate and complete?
As you’ve read, mistakes are commonplace. And inaccurate medical records can cause you harm. So, it’s worth the time and energy to check your records on a regular basis.
You have a right to see your records.
First of all, the 1996 HIPAA law guarantees your right to see your medical records.
And a new US federal rule called the “Cures Act Final Rule”, effective April 2021, requires that all healthcare providers give patients electronic access to all of their electronic health information — at no cost.
This new law requires all health provides to make information in 16 categories available electronically to patients, in a timely manner, upon request. The categories include clinical notes, allergies and intolerances, health concerns, assessment and plan of treatment, procedures, and problems.
How can you check to see if your medical records are accurate?
Although you have a legal right to get your records, it can be an easy process, or a complete hassle.
Importantly, many doctors and hospitals don’t know about the new Cures Act Final Rule, don’t think it applies to them, or are just not paying attention to it.
However, don’t give up without trying!
If your provider uses EHRs, ask for a printout of the appointment notes before you leave. Additionally, it might be possible for you to access your appointment notes through your doctor’s or hospital’s online portal. However, you may find the information available on the portal is brief and does not include detailed notes from the doctor. In this case, you will need to ask your doctor to provide you with their appointment notes from your visits.
On the other hand, if your provider uses paper records, you’ll probably have to fill out a form to get copies. And you might have to pay a copying fee.
What about old records?
You may want to see old records if you are changing doctors or dealing with a long-term condition. If your old records still exist, you should be able to get a copy.
State laws determine how long a provider must keep your health records — and the requirement varies by state. If you haven’t been to your provider in more than 7-10 years, your records may be archived — but you still have the right to get a copy, as long as the records still exist.
For more information, read Tips for Getting Copies of Your Medical Records.
What kind of mistakes should you look for?
The US government office on Health Information Technology provides the following guidelines for checking your records.
Start by checking your personal information:
- Name, address, and phone.
- Insurance plan, including account number.
- Identification numbers, like your patient identification number or social security number.
Next, look for mistakes or out-of-date information that can impact how your doctor/provider diagnoses and treats you. Don’t worry about small typos, but if a mistake can affect your health, it should be fixed.
Check to see if your medical records are accurate for the following health information:
- Doctor’s appointment notes
- Health or medical history, including family history
- Allergies and intolerances
- Medications – prescription and over-the-counter
- Tests and results
Lastly, it’s always a good idea to compare your health records with your insurance statements so you can be certain you only receive bills for services you received.
What should you do if you notice your medical records are not accurate?
Unfortunately, today’s electronic health records don’t include a process for patients to comment on their records. But under HIPAA, if you think there’s a mistake in your health record, you have a right to ask your provider to fix it.
Contact your provider’s office and ask what steps you should take to have a change made in your health record. If it’s a simple mistake, like an incorrect phone number, you might be able to send the correction to your provider’s office through their online portal. But you might need to write a letter or fill out a form.
When notifying your doctor about a medical record error, include a detailed description of the mistake you found and how you think it should be fixed. And if possible, attach a copy of the page that includes the error. And make a copy of everything you send for your own records.
However, it’s important to realize that doctors have the right, and responsibility, to express medical opinions in your record, even if you don’t like what he/she says. And if they leave out important health facts and risk factors, they can face legal and ethical problems.
You’ve notified your provider, then what happens?
Doctors and hospitals must respond in writing within 60 days, unless they file for an extension. Don’t be surprised if get a little bit of a run around – as doctors, nurses, and administrative staff each point you in a different direction.
Importantly, medical providers are not obligated to accept your request. They can refuse to make a change, but they must specify the reason in writing.
If your provider rejects your suggested change, you have the right to add a statement contesting this decision to your medical record. Additionally, you can file a complaint with the government office that oversees HIPAA or a state agency that licenses doctors.
Why would a provider reject your correction?
Your doctor might not agree with the changes you are requesting. For instance, if you ask your doctor to remove sensitive information about drug or alcohol use, your doctor will likely want to keep this information in your record because it’s directly related to your health and well-being.
In an ideal world…
Ideally, each of your doctors would give you a copy of the records pertaining to each visit before you leave the office. Time is not your friend. The sooner you identify and correct mistakes, the better. So, take a few moments to determine if your medical records are accurate and let your doctor’s office know if you see an issue.
Also, realize that the doctor’s notes are brief. You should still take your own notes at every appointment. For more information, read Why Take Detailed Notes at Doctor Appointments?
NOTE: I updated this post on 8-28-23.