Is that what I said? That’s not what I meant! Now what? Part 2

You took the time to prepare for your visit with your doctor. You asked your doctor to explain her observations with words you understand, you told her what you thought you heard, and she confirmed it.

You request a copy of you medical record or log onto your patient portal a few days later, and read your doctor’s notes. You see an error, maybe your birthdate or your medications are wrong, or there’s something there you know you didn’t say, or the doctor didn’t say to you. And now it’s there in back and white.

Why does that matter?

Our medical records, including test results and doctor’s and nursing notes are the “source documents” for our health care. In accounting, a source document is the original record that contains the details to substantiate a transaction. In health care, our medical record is the source record that contains the “facts” of every medical encounter we have. So if something in that record isn’t accurate, the downstream effects can range from inconsequential to pretty serious.

There are two kinds of errors: 1) An error which can be factual, like a date of birth, medications or 2) an error resulting from interpretation of information exchanged during the appointment (Ex. a patient states they have two glasses of wine at night appearing in the notes as “patient self-reports heavy drinking”). A first reaction is: “I didn’t say that; I’ll tell them to correct it.” Unfortunately it’s not that easy.

It’s a common misunderstanding that a medical record belongs to the patient. In fact though, in many states the ownership of a patient’s medical record isn’t legally specified. In 17 states the statutes specify that the physical medical record belongs to the doctor or hospital that generated it.

Fun fact: New Hampshire is the only state in which patients actually own their medical records. However, no matter how your state has defined ownership, the laws in most states require that a copy of the record must be provided to the patient on request.

Amending or changing a medical record is governed by HIPAA, which specifies how health information has to be protected. The process is strict, often individualized to the practice or institution to request a correction to a medical record after an encounter. Generally,

  • A patient must make a request in writing to the physician or institution where the record is stored, clearly noting what part of the record they are requesting be deleted or changed (amended), signing and dating the request.
  • The patient specifies in their request how they would like the record changed.
  • The doctor or hospital discusses the request to determine a response, and notifies the patient of their decision.

If the doctor or institution agrees with the patient’s request they can add a note to the medical record indicating “per patient request, the record is amended as follows” and make the appropriate change(s). They also must sign and date the note, and some sources feel the provider has an obligation to share the amendment with any entity that has previously received that patient’s records. Unfortunately this isn’t a legal obligation though.

If on the other hand, the doctor or hospital doesn’t agree with the patient’s request, they will typically reply in writing in (hopefully) plain language why they don’t agree. There should be additional language as to how a patient can submit a reply to this denial, and the patient can request that all of the correspondence be included in their record if any other provider ever requests records from that provider.

What can an empowered patient do?

  • Request your doctor’s notes after a visit. There is a body of well-documented evidence that indicates that patient health improves when patients have access to their records. An article published in Forbes last year noted that when patients have rapid access to the notes from their medical visits it improves their ability to remember the care plan, adhere to medications, positively impacts patient/physician communication, and ultimately improves the quality of the data. (i.e. those errors and misunderstandings get corrected quickly!) Correcting errors at the next visit is far easier than having to go through the formal amendment process.
  • Keep your own personal file of your source medical documents. While you may not own your medical records (unless you live in New Hampshire!) you can still request copies, and if you have a complicated health history, having copies of your medical records means you have the source documents if you ever need them for a second opinion or establishing with a new physician. And you then know what’s in them if corrections need to be made.
  • Until access to our health record gets easier (Apple is reportedly considering ways for patients to get and store medical records on the iPhone), consider subscribing to a tool like PicnicHealth or CareSync. These tools are web-based portals that support obtaining your medical records electronically and more efficiently than paper records. They’re stored for your use and accessibility on demand, even after your subscription expires.
  • If you find errors in your medical records that you believe will impact your care going forward, find out how to request that they be corrected. Our practice found an error in one record that someone clicking a wrong box on a hospital admission had incorrectly indicated the patient’s race in their hospital record. This was important because certain lab tests have different “normal” values depending on race and the reporting and interpretation is often automated based on the patient’s electronic profile. If your provider can update the information in the next visit note, and if your past records are unlikely to be needed going forward, that may be sufficient.
  • What about “interpretive errors?” Healthcare providers are trained in their documentation of patient histories not to interpret the information patients provide even as they take it into consideration with their observations and data they obtain to help us. All the same, doctors are humans first and doctors second. Sometimes in a rush (or to be less generous, when they are less aware of their own prejudices or biases) their note will interpret or paraphrase something you said as though it was what you told them.

In the perfect world we would try to have a conversation about it with the doctor, but sometimes it may have been a single visit, or a situation where the provider isn’t open to changing their interpretation. If you’ve exhausted all the efforts outlined above, call our office to discuss next steps.

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