1/10/2019 by Share Your Story

Mistakes in Medical Records: 4 Tips

Diane Talbert psoriasis advocate, talks about the dangers of finding mistakes in medical records and what you should do about them.


I have been seeing doctors for my disease (psoriasis) since the beginning of time. In 1963 I saw my first dermatologist and have seen hundreds of doctors over the years. I have found mistakes in medical records of mine but never paid much attention to them.

MISTAKES IN MEDICAL RECORDS

I recently had to have a procedure done and the test report got misfiled because of a mistake on the report. When I went back to the doctor he was confused and angry to have to go looking for the correct results (he even used some bad language). This was far more than just an in-office inconvenience. I was unable to get pre-authorization for a treatment I was having with him because the insurer, due to this error, thought my pre-testing wasn’t done.

It made me look closer and I found that my medical records were a hot mess. There were LOTS of mistakes. I sent emails to all my doctors asking for permission to review my medical records.

THE DANGER OF ERRORS

I remember my doctor asking me years ago, what dose was my insulin? Huh? I wasn’t on insulin. I take Metformin for my Type II diabetes. This is a serious mistake. That could affect my insurance coverage or worse, would lead to prescription errors that could make me sick, even dead! Mistakes in medical records can be life threatening. They can prevent insurers from covering things we need. The seriousness of wrong information in the records doctors use to make medical decisions about our health cannot be overstated.

WHAT CAN YOU DO?

  1. What can you do to make sure your records are accurate? I would contact the doctor’s office first. Ask to see your chart. It is important that we find out if our records are accurate. Remember, legally, those are YOUR records. The information does not belong to the hospital or the doctor.
  2. It’s never too late to start creating better records now on your own. Make sure you are using the same, legal version of your name all the time for starters. If you are “Mary Smith” here, “Marie Smith” there, or “Marie M. Smith” somewhere else, that’s a recipe for trouble.
  3. Get to know your doctor and find out if your doctor is putting accurate information into your records. it’s important you be as clear and accurate as possible though. If you are unclear then your doctor could be misinterpreting what you are saying. If you are clear and your doctor just isn’t listening to you, it’s time for a new doctor.
  4. As a person with so many illnesses I can confuse the best of doctors. I have been in doctor’s offices crying more times than I can remember. I am often overwhelmed when I am talking to my doctors. There have been days when I have been in so much pain that I probably confused the doctor as much as myself. So when you are with your doctor do your best to be clear and not emotional. We can’t always, I know, but it’s good the more control you have.

NOTE FROM THE EDITOR:

When you discover an error in your medical record you have a legal right to correct or amend them. The code of federal regulations (CFR) and the Health Insurance Portability and Accountability Act (HIPAA) afford you the right to request an amendment to medical records.

The Code of Federal Regulations, §164.526 states that an

“INDIVIDUAL HAS THE RIGHT TO HAVE A COVERED ENTITY AMEND PROTECTED HEALTH INFORMATION OR A RECORD ABOUT THE INDIVIDUAL IN A DESIGNATED RECORD SET.”

For an explanation of that click here for our article on Demanding Accurate Medical Records.


Diane Talbert is a blogger, patient advocate and speaker for psoriasis and psoriatic arthritis. She has been an Diane Talbertadvocate for this disease for over a decade now. Diane has run support groups in the Maryland, DC and Virginia area, is a volunteer for several organizations and vows to help find a cure for psoriasis and psoriatic arthritis and stop the stigma associated with it. She loves being a wife, mother and grandmother.


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