Medical records include exactly what you expect—a record of a patient’s health and medical history. Depending on the individual, these records could include information about treatments and medications, alcohol consumption habits, family medical history, and allergies. Regardless, these documents are key to recording and receiving medical care.
Unfortunately, even with (and sometimes due to) the introduction of electronic health records, errors abound. In an interview with CNBC, sociologist Ross Koppel, PhD, said that “about 70 percent of patient records have wrong information.” Similarly, the Office of the National Coordinator for Health Information Technology found that 23 percent of people who accessed online medical records requested corrections—that’s 1 out of every 10 people.
These errors in medical records aren’t just an inconvenience; these mistakes can lead to misdiagnoses, erroneous allergy information, and medication combinations that result in additional injuries or even death.
Additionally, incorrect contact information (name, address, phone number, etc.) could lead to issues when it comes to receiving bills or lab results.
Errors commonly found in medical records include the following.
Long and complicated medical histories—especially those of senior adults—may result in records going missing or inaccurate information getting lost in the shuffle. When decades worth of data is at stake, records can get disorganized.
Some misspelled words will not impact a patient’s health and therefore may not need to be corrected. However, errors in the spelling of a patient’s name, for example, can cause complications when it comes to sharing records among providers and should be fixed as soon as possible.
If one patient has the same name as another, the records could get mixed up. A patient’s history and information could be placed in the wrong file, or the entirely wrong file could be given to the wrong person.
Phone numbers and addresses that are out of date or incorrect can lead to issues with billing or contacting a patient about lab results or treatment updates.
Faulty lab results or other diagnostic errors, if included in medical records, could lead to patients being treated for health conditions they do not have.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) ensures your medical records are private and gives you the right to ask for corrections to any errors you find. However, even if you request amendments to your medical records, a doctor or medical provider may refuse to do so.
Before you can correct mistakes in your medical records, you have to review those records and see if they have any errors.
Some healthcare systems have patient portals on the web, allowing patients to have easy and convenient access to their medical data. You can check your medical records online through that system.
You can also see your medical records by obtaining copies directly from the doctor, hospital, or medical provider. In most cases, all you need to do to access your medical records is submit a written request or fill out a form. Thanks to HIPAA, medical providers cannot deny your request due to unpaid medical care; however, they may request a fee for copying and mailing your records.
Finding medical records from 20 or more years ago can be challenging, because doctors retire or hand over their practices, and documentation can fall through the cracks. If your medical provider does not have access to older medical records, contact your local health department.
Once you have your records, review them carefully and make note of any errors you find.
After you find errors in your medical records, you need to request that those mistakes are corrected. Most hospitals, medical offices, or other healthcare providers will have a form to fill out, but others may require a written letter.
When detailing the errors you found, be as clear and concise as possible. You want to make it easy for the office to know exactly what changes and updates they should make.
To support your request, include a copy of the pages of your records that contain errors. Then, either mark and fix the mistakes or write a note outlining what is wrong and how the information should be changed.
The hospital or medical provider has 60 days to act on your request, a timeline that can be extended by an additional 30 days. After the hospital has reviewed your request, they will either accept or deny your changes.
If they deny your request, they must notify you of their decision and include both a record of your request as well as their denial in your medical records. However, a denial is not necessarily the end. You can contest their decision or file a complaint with the local, state, or federal health department.
When preventable medical record errors cause serious injury or even death, the patient may be able to pursue a medical malpractice case. Mistakes happen in medical records, but if those errors are caused by negligence and if a patient is injured as a result, legal action may be the next step.
If you or a loved one have been injured as a result of medical record errors, contact the Indianapolis Medical Malpractice Attorneys of Wilson Kehoe Winingham. The lawyers at WKW can help you and your family get the compensation you deserve. Call 317.920.6400 or fill out an online contact form for a free, no-obligation case evaluation.
Let WKW put our experience to work for you. Contact us for your free case evaluation.