Accurate medical records are essential for receiving the best healthcare possible. Clearly, your doctor may treat you inappropriately if your records contain wrong or incomplete information. Unfortunately, health records can include mistakes about any aspect of a patient’s health and his/her medical and family history. Whether your doctors use Electronic Health Records (EHRs) or paper records, the risk for mistakes is real. Are your medical records accurate? Maybe not! Read on to learn how and when to evaluate your records and what to do if/when you find a mistake.
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. This is true for the records kept by individual doctors, large group practices and hospitals.
NOTE: In this post, the term “provider” includes all medical professionals as well as hospitals.
How do mistakes in medical records happen?
In a nutshell, most mistakes come from human errors or electronic systems design flaws.
Paper and electronic records can contain errors.
All people make mistakes, and that includes all providers. Doctors and medical staff are stressed and overworked and appointments are often rushed. In this environment, it’s easy to understand how mistakes occur, including when:
- Your provider enters incorrect information or leaves something out.
- He/she confuses you and/or your history with another patient.
- Your provider accidentally transposes numbers on a diagnostic code or test result.
- He/she misunderstands what you say and therefore enters incorrect information.
- You forget to tell your provider about an issue, like a new symptom, medication or allergy.
EHR design can cause errors.
EHRs come with their own set of pitfalls for errors. According to an article in Medical Economics, 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 realize it, 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.
How can these mistakes 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 diagnoses and treatments. Imagine if your record mistakenly states that you have a serious illness. Or your record doesn’t include information about a severe allergy to a medication. Not only can mistakes like these lead to frustrating conversations with your medical team, it can be dangerous. For instance, if you are in the ER and are too sick or injured to communicate, the staff must rely solely on your medical record. It’s easy to see the potential for huge problems if they rely on information that is not correct.
Importantly, if you do not notify your doctor or hospital about mistakes you find, these mistakes may follow you for years and years.
The potential for billing errors.
Your record might state you received a test or treatment that you never had, which can lead to erroneous bills.
You should check your records. Often.
Mistakes are more common than you think. Researchers found that almost 10% of people who check their online health record ask to have a mistake corrected. And remember, mistakes in your records can lead to dangerous health related complications.
First and foremost, the HIPAA law guarantees your right to see your medical records. This can be easy or a hassle, so be prepared. If your provider uses EHRs, ask for a printout of the appointment’s records before you leave. In many cases, you can also check the details of your record through your doctor’s or hospital’s online portal. But 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 5 years, your records may be archived — but you still have the right to get a copy, as long as the records still exist.
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, 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 your health information, including:
- Doctor’s appointment notes
- Health or medical history
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 see a mistake?
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 are needed to make a change 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. Either way, be sure to 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. Make a copy of everything you send for your own records.
You’ve notified your provider, then what happens?
Doctors and hospitals must respond in writing within 60 days, unless they file for an extension. But it’s important to understand that medical providers are not obligated to accept your request. 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, a patient might want his/her provider to remove sensitive information about drug or alcohol use. But a doctor will likely want to keep this information in the patient’s record because it’s directly related to a patient’s 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 and read through the notes 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.