Errors in medical records are relatively common. Helping older relatives review their medical records may uncover mistakes that could cause future harm. It is worth investing the time to make sure that errors in medical records are corrected.
Medical Records Errors
An expert in health IT told CNBC that 70% of medical records contain wrong information. The Office of the National Coordinator for Health Information Technology (ONC-HIT) determined that 10% of patients who accessed their records electronically asked their healthcare providers to correct errors in the records. However, most patients do not review their records and, when they find mistakes, most do not request a correction of the errors.
Errors occur for a variety of reasons. Kaiser Health News tells the story of a woman who reviewed her father’s medical records. She discovered that they contained entries that related to a different patient with the same name. Errors of that nature can lead physicians who rely on the records to draw incorrect conclusions about a patient’s health conditions or medications.
Omissions from medical records are often caused by neglect. Test results, prescriptions, allergies, and other vital information can be missing from medical records simply because they were never entered.
The consequences of medical record errors can be devastating. The Kaiser Health News story discusses a patient whose pathology report identified cancer after a biopsy. The report was not entered into a patient’s medical records, causing the cancer to go untreated. The patient died after the cancer metastasized.
In another case, records that accompanied an older woman to a rehabilitation center after a hip replacement stated that she had an underactive thyroid. She had actually been diagnosed with an overactive thyroid. If her son had not detected the error, she may have been prescribed medications that would have worsened her condition.
Review of Electronic Medical Records
During the last two decades, evolving federal laws have made it possible for many patients to view their healthcare records online. While patients always have the right to review their medical records, it can be burdensome to find a provider’s medical records department and to page through a file. In 2009, federal rules were implemented that create a financial incentive for Medicare providers to maintain their records in an electronic format.
The rules required healthcare providers who keep records in an electronic format to give copies of those records in the same format to patients upon request. The rules also required providers to transmit the records in electronic format to any entity authorized by the patient. A 2016 law mandated the creation of a framework that would make it easier for healthcare records to be transmitted electronically from one provider to another.
While the initial rules were cumbersome, the Center for Medicare and Medicaid (CMS) improved patient access by encouraging Medicare providers to make records available to patients online. More than half of Medicare patients are now offered online access to their medical records.
Correcting Errors in Medical Records
While electronic access to healthcare records makes it easier for patients to identify errors, it is not always easy to correct those mistakes. Still, patients have a right to ask doctors to fix errors. That process begins when patients or authorized family members review medical records to make sure they are accurate.
Simple errors can lead to long-term problems. An error in a patient ID number or the spelling of a name can cause one patient’s records to be confused with another’s. An error in emergency contact names and telephone numbers can prevent important information from being conveyed in a timely manner. The omission of an allergy or a medication can cause other doctors to make treatment errors in reliance on the incomplete information.
Federal rules give doctors 60 days to respond to requests to fix errors, although they can ask for a 30-day extension. When doctors deny a request to amend the record, they must explain their reasoning in writing. Patients cannot correct records on their own, although they can ask to have their own version of the facts added to the record.
Patients and their advocates can hope that conscientious doctors will correct obvious errors. When there is a dispute about the facts (such as what a patient said to a doctor during an examination), the patient’s only remedy may be to clarify her position by asking for her version of the facts to be added to the records.
At this point, no easy way exists to make that correction electronically. Patients generally need to send the physician a request by letter or email, placing the burden on the physician to make the correction or to explain the reason for denying the request.