Thursday, March 28, 2013

Medical Notes: When Doctors Get Them Wrong

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I spend too much time in doctors offices.  This is one of the many drawbacks of having an autoimmune disease and needing careful monitoring.  Doctors visits also mean keeping track of my medical records. This is no small task as many of you know who have serious health challenges.

Given my medical adventures over the last 5 years, not many problems and inefficiencies in healthcare surprise me.  One thing always does -- how often my physicians' notes contain mistakes regarding my past and current medical history.  Granted my history is far from simple -- it is complicated and certainly not standard for an average woman in her 30s.  But mistakes and inaccuracies in health records are serious business and can be dangerous (and even deadly) for patients.

I have found that once a mistake is made in my health record, it is often repeated by the next physician who reads them.  This has even occurred when I point out the various inaccuracies and mistakes with the goal of having them fixed.  In some instances, I have been treated as if I am confused about my own medical history.  It seems that once something is written by a physician even incorrectly, it becomes written in stone to other physicians.  It can become a Herculean task for a patient to have it fixed.

My way of dealing with this problem is far from ideal and quite time consuming.  I request that my physicians send their notes to me.  Now this is no easy feat.  Doctors offices and hospitals are often quick to send records to other physicians, but make it a long and difficult process for a patient to actually get their own records.  This occurs despite HIPPA regulations to the contrary.  

Once I actually receive my records, I then review them and ask the doctor to fix any significant errors in my medical history.  (This can certainly be an uncomfortable request to make and a couple of doctors have made it clear they were not happy with me for asking). It is only then that I send my medical notes to my other physicians.   This is not a strategy that I recommend to others especially during health crises because it can delay coordination of care.   

Some might think that I am overly vigilant about my medical records, but this goes beyond my type A personality.  Inaccuracies in my chart helped contribute to the long delay in my autoimmune diagnosis.  

Most patients would agree that they should have easy access to their medical records and should not have to jump through hoops to get them. One question I hear discussed--will the increasing adoption of electronic health records (EHR) improve the accuracy of patient records? It's a big question probably fitting for additional blog posts.  I have heard both sides of the argument and I'm really not sure. Will it make mistakes harder to enter my records? Or will it propagate these errors so I can't get rid of them? My current opinion is that it will depend on whether or not doctors and hospitals allow patients to contribute to their personal EHR and if they can access records and request corrections.  

What has been your experience accessing your medical records? How do you address inaccuracies when you find them?

1 comment:

  1. I finally came across someone that has the same concerns as I do! I am in the process of trying to obtain my FULL medical records, including, most importantly to my situation, my doctor's "NOTES" on me!