Anyone can make a mistake — even your health care provider. And sometimes, those mistakes end up in your medical records. That can cause a variety of issues, including misdiagnosis, medication interactions, missed follow-up testing and care, duplicate testing and billing errors. Fortunately, HIPAA gives you the right to request a copy of your medical records from any health care provider who has treated you so that you can review the information and check for errors.
The issue is more common than you may be aware of. A study published in BMJ Quality and Safety found that 29 percent of the study’s participants found the information they believed was incorrect in their health care provider’s visit notes. In addition, a poll by the Kaiser Family Foundation noted that one in five people reported errors in their medical records, including both incorrect personal information and incorrect information about their medical history, test results, and the medications they had been prescribed.
What causes medical record errors?
Several different issues can result in medical record errors, including:
- Health care providers or support staff inputting incorrect or incomplete information, cutting and pasting incorrect information from older records or identifying the patient incorrectly
- Electronic health record (EHR) systems used by different providers and health care facilities that do not communicate with each other, leading to fragmented and incomplete records
- EHR system failures and data breaches
- Delays in information, such as test results, new prescriptions and hospitalizations, being added to your medical record
The benefits of reviewing your medical records
Not only does taking the time to regularly review the information in your medical records give you the chance to catch and correct errors, but it can also be helpful in other ways:
Preparing for an appointment. Reviewing your health care provider’s notes from previous appointments can help you develop a list of questions you’d like to ask and issues you’d like to revisit at your next appointment. If your doctor recommended weight loss as a first step to lower high blood pressure, for example, you can ask if your blood pressure has improved enough or if you should consider medication to manage it.
Taking the time to understand what your provider has said. For many people, being in a provider’s office can be a stressful experience that makes it harder to focus on the information being shared with you. That’s especially true when you’ve been diagnosed with a serious health problem, or your provider recommends a surgical procedure. Reviewing the information in your medical records and visit notes at home gives you the opportunity to take in the information at a time when you’re less likely to be anxious, distracted, or feel rushed.
Clearing up any misunderstandings. If your doctor used terms that you didn’t understand during your appointment, you can find them in your visit notes, then get in touch with your health care provider to ask for clarification in plain English. You can also ask if there are any resources they recommend to help you better understand your condition and treatment plan.
Filling in gaps. There’s a lot going on during health care appointments, and even well-prepared patients can forget to share key information. After reviewing your medical records, if you realize you didn’t share important information like your family history, allergies, previous diagnosis or treatment, current medications or new symptoms, contact your provider and share the missing information.
Ensuring your providers know about each other. If you see more than one provider, for example, a primary care physician, an orthopedist and an OB/GYN, reviewing your visit notes and making sure that they are shared with all the health care providers who are treating you can help decrease your risk of overtreatment, medication interactions, overprescribing and duplicate testing.
Preventing and catching billing errors. By reviewing your visit notes, you have the chance to make sure that the care that’s listed in your record is the care you actually received. For example, if the notes say your provider performed a strep test, but you didn’t have that test, call or email the office to correct the error, so you and your insurance carrier are billed only for the care you received.
Miles J. Varn is chief executive officer, PinnacleCare, and can be reached on LinkedIn.
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