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How to Review Your Medical Records for Errors

Fixing These Mistakes Can Have an Impact on Your Diagnosis and Treatment

By

Updated April 11, 2011

With the advent of electronic medical record keeping, and the instant transfer of medical information between doctors, hospitals, testing centers and other facilities, it becomes imperative that patients keep track of those records, and correct any errors that occur.

My own story of misdiagnosis illustrates this point:

When I first visited my primary care physician because of a golf-ball sized lump on my torso, he asked me the questions one might expect; when had it first appeared, and whether it was painful. At that time, I had no idea it was good practice to request copies of my medical records; it never occurred to me that there could be errors, either.

Part of my misdiagnosis discovery goes back to that visit. When I finally reviewed my records, including the doctor's notes, I learned the lump had been recorded as "red and painful." In fact, it wasn't red, and it wasn't painful at all. It was just there.

It's possible that error in my doctor's notes led the pathologists who reviewed the biopsy of that lump to determine it was a cancerous piece of tissue; meaning, had I caught that error immediately, I might never have been misdiagnosed with cancer.

What Records Need Review?

  • Doctor's and other provider's notes about your visits with them
  • Medical test results
  • Records kept by any testing centers, hospitals, or other facilities you visit
  • Information from the Medical Information Bureau (if such records exist)
  • Insurance billings and codes
  • In particular, the shift to electronic medical records can create problems.

It may be difficult to obtain all these records, but it's definitely worth the trouble so you can correct the information listed below.

What Information Needs to be Corrected?

Check your identification information to make sure your name, address, phone, and others are correct. Report any discrepancies to the person who made the error. Ask them to correct the notations while you wait.

Review any notes taken about your meetings to be sure symptoms and test results have been recorded correctly. Again, report errors to the person who made them, and ask them to make the correction immediately. If you don't see them make the correction, then follow up later to be sure it has been taken care of, or follow the more formal procedure outlined by HIPAA laws.

Health insurance billing needs to align with the services you received. You'll do this after you receive the billing notice from the insurance company, and you've lined up the services they report with the services on the receipt given to you by the doctor's or facility's office. If they are incorrect, report them to your insurer.

What Should You Do If Errors Are Discovered?

If an error can have an impact on your future dealings with the provider, or on your health or future health, or can even lead to medical identity theft, you'll want to correct the error. There are specific steps to take to make those corrections.

Information from the Medical Information Bureau gets corrected through its own procedure.

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