Check Your Medical Records For Dangerous Errors By Liz Tidy

Check Your Medical Records For Dangerous Errorswhen Liz Tidymans Elde

Check Your Medical Records For Dangerous Errorswhen Liz Tidymans Elde

Check Your Medical Records For Dangerous Errors When Liz Tidyman’s elderly parents moved across the country to be closer to their children and grandchildren years ago, they carried their medical records with them in a couple of brown cardboard folders tied with string. Two days after their arrival, Tidyman’s father fell, which hadn’t happened before, and went to a hospital for an evaluation. In the waiting room, Tidyman opened the folder. “Very soon I saw that there were pages and pages of notes that referred to a different person with the same name — a person whose medical conditions were much more complicated and numerous than my father’s,” she said. Tidyman pulled out sheets with mistaken information and made a mental note to always check records in the future.

“That was a wake-up call,” she said. Older adults have cause to be careful about what’s in their medical records. Although definitive data aren’t available, the Office of the National Coordinator for Health Information Technology estimates that nearly 1 in 10 people who access records online end up requesting that they be corrected for a variety of reasons. In the worst-case scenario, an incorrect diagnosis, scan, or lab result may have been inserted into a record, raising the possibility of inappropriate medical evaluation or treatment. This, too, is something that Tidyman’s father encountered soon after moving from Massachusetts to Washington. (Her parents have since passed away.) When both his new primary care physician and cardiologist asked about kidney cancer — a condition he didn’t have — Tidyman reviewed materials from her father’s emergency room visit.

There, she saw that “renal cell carcinoma” (kidney cancer) was listed instead of “basal cell carcinoma” (skin cancer) — an illness her father had mentioned while describing his medical history. “It was a transcription error; something we clearly had to fix,” Tidyman said. Omissions from medical records — allergies that aren’t noted, lab results that aren’t recorded, medications that aren’t listed — can be equally devastating.

Susan Sheridan discovered this nearly 20 years ago after her husband, Pat, had surgery to remove a mass in his neck. A hospital pathology report identified synovial cell sarcoma, a type of cancer, but somehow the report didn’t reach his neurosurgeon. Instead, the surgeon reassured the couple that the tumor was benign. Six months later, when Pat returned to the hospital in distress, this error of omission was discovered. By then, Pat’s untreated cancer had metastasized to his spinal canal. He died 2½ years later.

“I tell people, ‘Collect all your medical records, no matter what’ so you can ask all kinds of questions and be on the alert for errors,” said Sheridan, director of patient engagement with the Society to Improve Diagnosis in Medicine. In less dire scenarios, a patient’s name, address, phone number, or personal contacts may be incorrect, making it difficult to reach someone in an emergency or causing a bill to be sent to the wrong location. Or, your family history may not be conveyed accurately. Or, you may not have received a service recorded in your record — for instance, a stress test — and want to contest the bill.

Dave deBronkart, a 68-year-old cancer survivor and patient activist, recounts mistakes he and his family have experienced. Once, he checked a radiology report through a Boston hospital’s patient portal. It had his name on it but identified him as a 53-year-old woman. In another instance, the records that accompanied deBronkart’s mother to a rehabilitation center after a hip replacement incorrectly identified her as having an underactive thyroid when she actually had an overactive thyroid. DeBronkart’s sisters, who asked to look at their mother’s chart, discovered the mistake and had it fixed on the spot, so she wouldn’t get potentially harmful medications. “It’s important for people to realize how easy it is for mistakes to get into the system and for nobody to know it. And that can cause downstream harm,” deBronkart said.

The law that guarantees your right to review your medical record, the Health Insurance Portability and Accountability Act of 1996, offers some recourse: If you think you’ve discovered an error in your medical record, you have the right to ask for a correction. Start by asking your doctor or hospital if they have a form (either a paper or electronic version) you should use to submit a suggested change. A simple error such as a wrong phone number can be corrected by drawing a thin line through the material and writing a suggested change in the margins or making an electronic note.

A more complicated error such as incorrect description of your symptoms or a diagnosis that you’re contesting may require a brief statement from you explaining what material in the record is wrong, why, and how it should be altered. Physicians and hospitals are required to respond in writing within 60 days, with the possibility of a 30-day extension. Some states set shorter deadlines. But medical providers are not obligated to accept your request. If you receive a rejection, you have the right to add another statement contesting this decision to your medical record. You can also file a complaint with the government office that oversees HIPAA or a state agency that licenses physicians.

Devin O’Brien, senior counsel with The Doctors Company, the largest physician-owned medical malpractice firm in the U.S., notes that rejections can be warranted when facts or medical judgments are in question. For example, a patient who wants a doctor’s notes about potentially excessive opioid use eliminated from the record might be refused if the physician believes the patient has an issue. Another example is a diagnosis removed from a record because it might compromise insurance coverage, which is not an acceptable reason for a correction.

For more information about correcting errors in medical records, see resources from the Office of the National Coordinator for Health Information Technology, the Privacy Rights Clearinghouse, and the Center for Democracy & Technology.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been experiencing with your care, and advice you need related to navigating the healthcare system. Visit khn.org/columnists to submit your requests or tips.

Paper For Above instruction

Ensuring the accuracy of medical records is fundamental to providing quality healthcare and protecting patient safety. Errors in medical documentation can lead to misdiagnoses, inappropriate treatments, and even life-threatening situations. Both patients and healthcare providers share the responsibility of verifying and correcting medical records. This essay discusses the significance of reviewing medical records for errors, common types of mistakes found, the legal rights patients possess for correction, and strategies to effectively manage and address inaccuracies.

Importance of Reviewing Medical Records

Medical records are the foundation for clinical decision-making, research, billing, and continuity of care. Inaccuracies within these records can have serious consequences. For instance, a misdiagnosis or incorrect information regarding allergies can lead to harmful treatments. Patients, especially older adults or those with complex health histories, should routinely review their records to ensure accuracy. The case cited by Liz Tidyman illustrates how clerical errors—such as confusing one patient with another—can create significant issues in healthcare delivery. Additionally, inaccuracies may result from transcription errors, outdated information, or incomplete data.

Types of Errors in Medical Records

Errors can be broadly categorized into errors of commission and omission. Commission errors include incorrect entries such as misdiagnosed conditions, incorrect medication lists, or wrong laboratory results. For example, listing kidney cancer instead of skin cancer can lead to unnecessary procedures or treatments. Omission errors involve missing crucial information like allergies, lab results, or medications that can cause adverse events or suboptimal care. Errors related to personal demographics—such as incorrect names, addresses, or contact details—can hinder emergency responses or lead to billing mistakes. In some cases, even minor inaccuracies can cause significant harm or confusion.

Legal Rights and Procedures for Correcting Medical Records

The Health Insurance Portability and Accountability Act (HIPAA) provides patients with the legal right to review and request corrections to their medical records. Patients should start by contacting their healthcare provider and requesting the appropriate form—either paper or electronic—to suggest edits. Simple errors, such as incorrect phone numbers, can often be corrected with a strikethrough and handwritten or electronic note. More complex issues, such as contesting a diagnosis or medical description, may require a written statement detailing the correction request. Healthcare providers are required to respond within 60 days, with some exceptions for extensions. If a request is denied, patients have the right to add a rebuttal statement to their records or file complaints with regulatory agencies.

Challenges in Correcting Medical Records

Correcting errors can be challenging, especially when disagreements arise over medical judgments or diagnoses. Healthcare providers are permitted to reject correction requests if they believe the changes are unwarranted or if the correction might influence insurance coverage or healthcare decisions negatively. This highlights a key distinction between errors based on factual inaccuracies and subjective clinical judgments. For example, a patient requesting removal of a diagnosis related to medication use may be refused if it reflects a clinical assessment, not an error.

Strategies for Patients to Ensure Accurate Records

Patients should proactively request their medical records, review them thoroughly, and compare them with their personal health history. They should document discrepancies clearly and submit formal correction requests following the provider’s procedures. Maintaining a personal health record can also help cross-verify information. Engaging in open communication with healthcare professionals about findings and concerns fosters a collaborative approach to maintaining accurate data. Educating oneself about legal rights and available resources, such as patient advocacy groups and official guidelines, empowers individuals to address errors effectively and prevent adverse health outcomes.

Conclusion

Maintaining accurate and complete medical records is vital for safe and effective healthcare. Patients must be vigilant in reviewing their medical information for errors or omissions. Understanding their rights under HIPAA and knowing how to request corrections ensures that inaccuracies are rectified promptly. Healthcare providers, meanwhile, should facilitate transparency and responsiveness to patient concerns. Ultimately, a shared commitment to record accuracy enhances trust, reduces preventable harm, and fosters better health outcomes for all.

References

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