When Liz Tidymanās 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, Tidymanās father fell, which hadnāt happened before, and went to a hospital for an evaluation.
In the waiting room, Tidyman opened the folder. āVery soon I saw that there were pages and pages of notes that referred to a different person with the same name ā a person whose medical conditions were much more complicated and numerous than my fatherās,ā she said.
Tidyman pulled out sheets with mistaken information and made a mental note to always check records in the future. āThat was a wake-up call,ā she said.
Older adults have cause to be careful about whatās in their medical records. Although definitive data arenāt available, the 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 Tidymanās 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 ā a condition he didnāt have ā Tidyman reviewed materials from her fatherās emergency room visit. There, she saw that ārenal cell carcinomaā (kidney cancer) was listed instead of ābasal cell carcinomaā (skin cancer) ā an illness her father had mentioned while describing his medical history.
āIt was a transcription error; something we clearly had to fix,ā Tidyman said.
Omissions from medical records ā allergies that arenāt noted, lab results that arenāt recorded, medications that arenāt listed ā 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 didnāt 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, Patās untreated cancer had metastasized to his spinal canal. He died 2½ years later.
āI tell people, āCollect all your medical records, no matter whatā so you can ask all kinds of questions and be on the alert for errors,ā said Sheridan, director of patient engagement with the Society to Improve Diagnosis in Medicine.
In less dire scenarios, a patientās name, address, phone number or personal contacts may be incorrect, making it difficult to reach someone in the event of 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 ā for instance, a stress test ā 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 hospitalās patient portal. It had his name on it but identified him as a 53-year-old woman.
In another instance, the records that accompanied deBronkartās mother to a rehabilitation center after a hip replacement incorrectly identified her as having an underactive thyroid when in fact she had an overactive thyroid. DeBronkartās sisters, who asked to look at their motherās chart, discovered the mistake and had it fixed on the spot, so she wouldnāt get potentially harmful medications.
āItās 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,ā deBronkart said.
The law that guarantees your right to review your medical record, , offers some recourse: If you think youāve discovered an error in your medical record, you have the right to ask for a correction. (For more information about how to obtain your record, see my earlier column here.)
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 youāre 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 or a state agency that licenses physicians.
Devin OāBrien, 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. An example might be a patient who wants a doctorās notes about potentially excessive opioid use eliminated from the record. āThe patient may say I donāt have a problem, I donāt know what youāre talking about, but the physician may think the patient has an issue,ā OāBrien said.
Another example might be a patient who wants a diagnosis eliminated from a medical record, because it might compromise her ability to get insurance coverage. That wouldnāt be an acceptable reason for making a change, experts said.
For more information about correcting errors in medical records, see from the Office of the National Coordinator for Health Information Technology, this from patient advocate Trisha Torrey, and these descriptions of your HIPAA rights from the and the .
Weāre eager to hear from readers about questions youād like answered, problems youāve been having with your care and advice you need in dealing with the health care system. Visit to submit your requests or tips.
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