By Lisa Zamosky
Many readers had something to say about a blog I wrote just after Christmas: Is it a Good Idea to Have Access to Your Doctor’s Notes?
The story outlines a recent study indicating that patients and doctors have different views about whether patients should be able to see medical notes placed in their chart by their physician. In short, patients want access to the notes while doctors seem more reluctant to show them.
What jumped out at me among the many comments left by readers was just how many people found glaring errors in their medical records. Their doctors, in some cases, included notes that in no way resembled their medical situation or the events patients recall having taken place in the exam room.
That begs the question: What do you do if you find an error or other information with which you adamantly disagree in your medical files?
Getting Hold of Your Files
So many of us appreciate the usefulness, even importance, of getting hold of our medical records, yet most of us don’t bother until we’re diagnosed with an illness that requires us to do so.
That’s a mistake. Just as you would check your credit report to prevent erroneous information from sabotaging your financial life, routinely taking a look at a copy of your medical records to make sure they’re accurate can offer you both medical and financial protection. The contents of your medical records can have real consequences
For example, starting in 2014, as a result of the health reform law, insurance companies will no longer be able to deny people insurance coverage on the basis of their health. But between now and then, if you need to buy insurance on your own, the contents of your medical record can make or break your ability to get coverage. Of course, they also play an important role in informing your doctors about your past care, which influences future treatment decisions.
In addition, you want to make sure that your demographic information – your name, address, etc. – is accurately reflected in your charts. I once had a $15 medical bill sent to collections because my doctor’s billing office was sending my mail to an address where I hadn’t lived for over two years.
For the protection of both your health and your finances, you need to know what your records show and take steps toward correcting any inaccurate information.
Gaining Access to Your Records
It’s your legal right to see your medical records. The best way to gain access is to talk with your health care provider about the specific process and/or forms they require in order for you to get them. If you have trouble getting your records (which is, unfortunately, common), read this earlier post for information about how to deal with the resistance.
Correcting Inaccurate Information
When it comes to your medical records, you have the right to see them but you don’t have the right to remove information you think is wrong or simply don’t want included. That’s because the information kept by your doctors and hospitals is a legal record of care and completely removing information would have potential implications for medical liability.
But under federal law, you do have the right to request that an amendment to information you think is incorrect be added to your file, even in cases where your doctor totally disagrees with your assessment. The entire package of information – your objections and possibly your doctor’s rebuttal of your claims – then travels with your medical records. Those amendments should also be sent to any other physicians or health care facilities that need access to your information.
On the Same Team
It’s not only in your best interest to bring errors found in your medical records to your health care providers’ attention. Doctors and hospitals have an interest – legally and clinically – in keeping them accurate as well.
There’s no good reason to believe that a doctor or other health care provider wouldn’t want to correct factual errors about which there is no dispute.
But I’d like to hear your experience. To all of the readers who commented on the mistakes found in medical records, did you attempt to make the correction noted? If so, what was the reaction you got? Sound off in the comments section below.
And for more information about getting and correcting your medical records, check out the Center for Democracy and Technology’s web page: Getting Your Medical Records.