topic Re: What if your medical records are wrong? in Wellness

What if your medical records are wrong?

AuntG — Wed, 26 Oct 2022 23:55:09 GMT

At a recent appointment, the doctor breezed in and said "I see you had a kidney stone in 2015". I immediately responded that I've never had one. He didn't seem to believe me, but then added he didn't see where I had any scans done that year which would have found a stone. Exactly, I silently thought! So I asked nicely if he could remove that notation and he said he couldn't.

Now a neighbor is being forced to use a "patient portal" at her clinic. As she worked her way through her electronic medical records, she saw a notation of "long time history of atrial fibrillation" which she has never been diagnosed with.

So my question is, what do you do when you find a glaring error in your medical records? When you say something, they just tell you that is what the doctor put in the notes. I tend to think the doctor put it in some other person's notes and they ended up in our records.

Re: What if your medical records are wrong?

Bhvbum — Wed, 26 Oct 2022 23:59:20 GMT

Do you have access to your medical records online? I do with "my chart".

There are a few errors, drugs that I had no "prescription" for even though they are listed, but they are also over the counter drugs which is confusing. Maybe the question is to ask, "since this is an error who is going to fix it?"

Note I always look at my doctor's notes that are posted after my visits and if I see anything that is incorrect I call the nursing assistant to let them know, and then I follow up if it's not fixed.

Re: What if your medical records are wrong?

RedTop — Thu, 27 Oct 2022 00:14:46 GMT

I would contact the office manager to ask what needs to be done to try to correct it.

Re: What if your medical records are wrong?

CoffeeNut — Thu, 27 Oct 2022 00:41:03 GMT

I doubt if they are allowed to delete anything.

I would have them put in your records that you reviewed your records on this date and the following items are incorrect.

I agree that you should contact the office manager and follow whatever protocols they have in place.

Insurances review medical records and you want to make sure everything is correctly documented to avoid any issues down the road.

Re: What if your medical records are wrong?

Tinkrbl44 — Thu, 27 Oct 2022 01:16:09 GMT

@AuntG wrote:
At a recent appointment, the doctor breezed in and said "I see you had a kidney stone in 2015". I immediately responded that I've never had one. He didn't seem to believe me, but then added he didn't see where I had any scans done that year which would have found a stone. Exactly, I silently thought! So I asked nicely if he could remove that notation and he said he couldn't.

Now a neighbor is being forced to use a "patient portal" at her clinic. As she worked her way through her electronic medical records, she saw a notation of "long time history of atrial fibrillation" which she has never been diagnosed with.

So my question is, what do you do when you find a glaring error in your medical records? When you say something, they just tell you that is what the doctor put in the notes. I tend to think the doctor put it in some other person's notes and they ended up in our records.

@AuntG

Wow, that's an interesting ... and important ... question.

I have received several emails telling me to sign up for a patient portal thing and always resisted. It never ocurred to me that I should check for errors!

Re: What if your medical records are wrong?

Icegoddess — Thu, 27 Oct 2022 01:28:40 GMT

I've never seen anything in my Patient Portal except things that occurred within that Portal system since I entered it. So, my Patient Portal with the local Hospital would only have things like my colonoscopy or mammogram results since both procedures were done within the Hospital's system. They wouldn't have my medical records from my doctors.

My PCP are all on paper. His office does not have a Patient Portal. My gyno records are on the computer since they enter new data every time I go, although I've never looked to see if they're actually available to me.

Re: What if your medical records are wrong?

Trailrun23 — Thu, 27 Oct 2022 02:39:12 GMT

When i was recovering from surgery in the hospita a few years ago, the dr asked if I had any pain and I said only in my shoulder. He said it must be from when I dislocated my shoulder five years earlier. I told him I had never dislocated my shoulder. He said I must have because it was in my medical record. I guess whatever gets in your record stays there? I tried to have it removed to no avail. I am quick to tell new doctors about the error.

The names of some of my meds are mispelled to the point they sound like totally different drugs...that could be dangerous.

Re: What if your medical records are wrong?

ZenaC — Thu, 27 Oct 2022 04:04:47 GMT

My mother experienced the same thing. Her records had her listed as a current smoker when she had not smoked in over 50 years. She told her doctor about the mistake and he said he would have it fixed. He didn't. Then his staff told my mom it couldn't be changed and that it made no difference anyway. Mom knew that wasn't right. Finally her doctor retired and she explained to her new doctor that she was not a smoker and that doctor said that she would fix it. Mom logged into her poratal and saw it was still there. She communicated somehow through her portal that she wanted that removed. Finally it was after years.

My grandmother was admitted to the hospital for gallbladder surgery. While there, she was told she might be diabetic. Turned out after follow up with her doctor she was not diabetic. Still, whenever she was hospitalized after that, diabetic was always pulled up on her hospital chart and they sent her diabetic meals. We had to explain to them that she was not diabetic and to order her regular meals. Diabetes was on her record until she died.

Re: What if your medical records are wrong?

ID2 — Thu, 27 Oct 2022 10:02:03 GMT

@Tinkrbl44

Why wouldn't you ever sign up to use your patient portal?!? It's a great way to view all of your medical records with that facility.

Re: What if your medical records are wrong?

granddi — Thu, 27 Oct 2022 13:14:15 GMT

And what is shown on the patient version of My Chart (or other formats) is not always what the provider sees. So there could be other conditions noted that the patient would consider to be incorrect.

I had a minor procedure with biopsy. At my follow up, the nurse handed me a print out of the lab report and said quietly "you need this" The top of the report said NOT FOR MY CHART

Friends pcp was filling out an insurance health application. It was noted COPD. My friend called doc and said WHAT? Reply from nurse was "if you have ever smoked then you have copd!"

Re: What if your medical records are wrong?

Sunshine Kate — Thu, 27 Oct 2022 13:17:37 GMT

I don't like Patient Portals. I have so many log in names/passwords already. I've tried the portals and tell the doctor's office I'm not using any of that anymore.

I'm always told, "We hear that a lot".

Re: What if your medical records are wrong?

Mj12 — Thu, 27 Oct 2022 13:26:05 GMT

I don't understand this reluctance to use patient portals. It puts all (or most) of your records in one place. It allows you to quickly communicate with your provider.

Re: What if your medical records are wrong?

tansy — Thu, 27 Oct 2022 17:28:51 GMT

@Tinkrbl44 Patient portals are good. I can access my lab values quickly. I can message a provider and get a quick response easier than trying to call in. Everything is there whether you choose to utilize it or not 🤷🏼‍♀️

ETA : I had mammograms performed at 3:45 yesterday. I just got an email to check the portal to see the results at 10:30 this morning. Benign. 😊

Re: What if your medical records are wrong?

TheOver40Diva — Thu, 27 Oct 2022 16:32:41 GMT

@AuntG Hi there! I've previously worked for a major healthcare system in their Privacy office and dealing with HIPAA related issues. Actually, this is a HIPAA related issue. According to 45 CFR § 164.526 - Amendment of protected health information, you have the right, as a patient, to request to have your medical record amended (changed). Each organization and state may have different ways they require this request be made. For example, in writing with a maximum number of words, etc. The people in the Privacy Office, or if it's a small organization they may use legal counsel, review your request and why you would like it changed. They will then find the original doctory, nurse, assistant, etc. who entered it into your chart and have them reveiw it as the patient is saying it is untrue. If it is in fact not true, for example, your medical record says you have diabetes, and you really don't. You have no testing that shows you are diabetic, etc. these requests are approved and are changed. On the other hand, if someone states they were in a motor vehicle accident and at the ER told the staff they were in the car with their sister, but the medial record states that the patient states they were in the car with the sister and her nephew. This type of request is 99.9999% of the time going to be denied because it's based on a fact a physician was told on the night of an incident. The patient then has a right to leave it alone, or write a statement that they disagree with what is in their medical record and every single time that that medical record is requested by anyone, the patient's statement is required to go with it. So if a request is ever denied, but you still want your version told, you can do so and have it made part of your medical record. This can get very confusing, so I hope I didn't do that to anyone. That's not my intention. I just thought I might be able to help out. Have a nice day!

Re: What if your medical records are wrong?

AuntG — Thu, 27 Oct 2022 22:43:56 GMT

That is very helpful @TheOver40Diva . I really want my records correct so I suppose I need to find out the process in my state.

Re: What if your medical records are wrong?

gardenman — Fri, 28 Oct 2022 12:58:01 GMT

The good news is even if something in your records is wrong, most sane doctors know to ignore it and trust the patient. There's not a lot they can't retest to verify who's right or wrong. Medical records aren't viewed by most sane doctors as being the gospel truth. They've all seen enough major screw-ups to know to trust the patient or their family members more than the records.

I wear a Medic-Alert necklace and was asking a doc once why no one ever checks it. He related a story of how when he was a young doc in the ER they had a teen-aged girl come in unconscious wearing such a necklace. It listed a very serious heart condition, and he was about to order a med that would be useful in such a patient but harmful for a "normal" person. The doc over him stopped him and made him wait for test results. It turned out she didn't have the heart condition. The necklace had belonged to her grandmother who had died, and she wore it as a memento.

Sane doctors will treat what they "know" is wrong with the patient first. They'll wait for testing or confirmation on anything in the records of whatever sort there are before acting on those. They know they can't trust the medical records. It may annoy you that it's in there, but in the real world, it probably won't affect the way you're treated.

Re: What if your medical records are wrong?

CatsyCline — Fri, 28 Oct 2022 16:06:24 GMT

Portals are usually 3rd Party. Doctors don't have the resources to admin. My PCP is on their fourth Portal system. They just merged with another practice. What happens to all the data when prior Portal system is eliminated. Is it archived, encrypted i have a portal with the Hospital where i've had 3 surgeries. So far their HIM and portal is not 3rd party.

Years ago, i saw a NP for anxiety before re-locating out of state. She shared office space with other medical providers and some therapists.

About a year after moving i requested my medical record. When i got the report in the mail i was stunned. Only a few lines were correct and they cut and pasted - in different fonts - into the report a number of other clients' serious Dx and personal data not intended for my eyes !! or anyone elses!

i asked the practitioner to remove the incorrect data. from her reaction i guessed she had not compiled the report herself.

Re: What if your medical records are wrong?

chrystaltree — Fri, 28 Oct 2022 21:13:22 GMT

@gardenman wrote:
The good news is even if something in your records is wrong, most sane doctors know to ignore it and trust the patient. There's not a lot they can't retest to verify who's right or wrong. Medical records aren't viewed by most sane doctors as being the gospel truth. They've all seen enough major screw-ups to know to trust the patient or their family members more than the records.

I wear a Medic-Alert necklace and was asking a doc once why no one ever checks it. He related a story of how when he was a young doc in the ER they had a teen-aged girl come in unconscious wearing such a necklace. It listed a very serious heart condition, and he was about to order a med that would be useful in such a patient but harmful for a "normal" person. The doc over him stopped him and made him wait for test results. It turned out she didn't have the heart condition. The necklace had belonged to her grandmother who had died, and she wore it as a memento.

Sane doctors will treat what they "know" is wrong with the patient first. They'll wait for testing or confirmation on anything in the records of whatever sort there are before acting on those. They know they can't trust the medical records. It may annoy you that it's in there, but in the real world, it probably won't affect the way you're treated.

Do you know many insane doctors????

Re: What if your medical records are wrong?

gardenman — Sat, 29 Oct 2022 12:53:19 GMT

"Do you know many insane doctors????"

I've come across a few in my 63+ years.

Re: What if your medical records are wrong?

Tinkrbl44 — Sun, 30 Oct 2022 03:24:53 GMT

Well, here's another wrinkle. A couple times I have told my doc something I didn't want her to write in my chart. She didn't enter anything, and told me she wouldn't do so.

NOT that paper charts are secretive, but you have to actually have it in your hands to read it.

Now that the visits are written into a chart on the computer, there's no telling how many can access the information.

Granted, there are a number of reasons "they" can access your medical information without your knowledge .... but it seems it's even less private -- or secure -- in a computerized system.