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Watch Out for Errors in Your Medical Records

Date: December 1, 2016      Publication: Bottom Line Health      Source:  Charles B. Inlander      Print:

You’ve probably heard plenty about medical errors that occur when a wrong drug is prescribed or a surgeon operates on the wrong body part. But there’s another type of medical error that needs much more attention than it’s getting: Errors in your medical records. More than just an administrative snafu, this type of mistake can have serious consequences—it can lead to inappropriate treatment, higher insurance premiums or even difficulty finding a doctor. And with electronic medical records that travel across computer networks in a matter of seconds, a wrong entry in your record can spread widely and be accessed by insurers, other doctors and hospitals before you even know it. To protect yourself from such mishaps, follow these steps…

  • Get your records. Under both state and federal laws, you have the right to receive a copy of your medical records. Most major hospitals, medical practices and insurance networks no longer keep paper records, opting instead for electronic record keeping. And those records are usually made available to you online. Beware: Not all doctors and hospitals share the same electronic record systems, so you may need to access several different online sources. Ask the doctors and hospitals you have used for access information. If you don’t have Internet access, you can ask for paper copies of your medical records—a verbal request usually suffices, but you may need to put it in writing. You may also be asked to pay copying fees. To avoid getting overwhelmed by massive records—for example, after a lengthy hospital stay—ask for copies of reports from tests on an ongoing basis and/or request a discharge summary from the hospital.
  • Review your records carefully. Look for gross errors such as a wrong diagnosis…medications you haven’t been prescribed…and/or medical procedures you have never undergone. Also look for anything that contradicts what you may have been told during an office visit. For example, your doctor may have said that your blood pressure is under control, yet the reading listed in your record may indicate that it’s not. You’d want to ask your doctor about this—you may need a different medication or change in the dose. Also: Be sure that your records have your correct contact information and that your name and insurance information, including policy number, are accurate. Such errors could mean the difference between an insurance payment and a denial.
  • Correct errors. Under federal law, you have the right to correct any error in your medical record. Do it in writing—by either crossing out the wrong information on a copy of the page where the error appears and writing in the correction…or by writing a more detailed explanation. Once the correction is received at the location where the record originated, the provider has 60 days to act on your request. This deadline may be extended by 30 days if the provider gives an explanation for the delay in writing. Technically, the correction is considered an “amendment” to your record—this may mean that the old, wrong information remains with the correction added. Even if your correction is denied, you can submit a letter of disagreement that must be put into your record. Important: Double-check your record online to ensure that the correction was made, and keep a copy of the correction for yourself to take to medical appointments in case the error lingers in another provider’s system.

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Source: Charles B. Inlander, consumer advocate and health-care consultant based in Fogelsville, Pennsylvania. He was the founding president of the nonprofit People’s Medical Society, a consumer advocacy organization credited with key improvements in the quality of US health care, and is the author or coauthor of more than 20 consumer-health books.