February is American Heart Month. That got me thinking about health in general, then about medical records. How accurate are they? Shockingly, not enough!
Years ago I needed the baseline x-ray of my lumbar spine from my hospital’s radiology department. They didn’t have it. Either someone signed it out and didn’t return it or it was lost. My doctor had to make treatment decisions, including surgery, without it.
Over time I discovered most of my doctors’ office notes had errors, some serious enough to warrant correction. Examples are:
- Medications I’d never taken and conditions I never had
- I never smoked (I smoked for many years but quit)
- My name was misspelled (which has prevented my records from being found)
- Primary doctor and treating doctor couldn’t find a record of my last colonoscopy – only after I told them the procedure date was it found buried in another report
According to my doctor, medical records only need to be kept for 10 years, after which they can be destroyed. (Laws and policies vary so check with your providers.) Here’s what became crystal-clear to me: I needed to keep copies of my own records. I suggest you do too.
Here are 5 tips.
- Get copies of all doctors’ office notes, lab reports, radiology reports and scans (on CD), operative notes and so on.
- Review each record for accuracy. If you find errors, have your medical provider correct them. A medical record cannot be changed but a note can be appended.
- File the records using a system that works well for you (e.g., by family member).
- Know what needs to be done and when. Did you know adults need a tetanus-diphtheria-pertussis (Tdap) booster shot every 10 years? I had to remind my doctor when mine was due.
- Check digital records too. My hospital and affiliated doctors initiated electronic records in 2013. My initial record had errors and I had my doctor correct them. But it still doesn’t contain important information such as surgical procedures, office notes from all but two doctors, and everything prior to implementation!
From fortherecordmag.com (on electronic records), “…the quality of medical records is not what it should be…in a report identifying the most challenging requirements of the first half of 2013, The Joint Commission (evaluates and accredits healthcare organizations) found 55% of hospitals did not maintain complete and accurate records for each patient.” That’s scary!
Medical decisions are based, in part, on data in your chart. I recall an accounting principle I learned in college: GIGO (garbage in, garbage out). If data are inaccurate, so will medical conclusions. Errors can have serious consequences. If you’re alone in an accident and unable to speak, your medical records may speak for you. Are you confident about what yours say?
I urge you to be proactive about your – and your family’s – medical records. This can be a big project. But what is more important than your health? Like any big project, schedule blocks of time and chip away. If you need help, contact me for a FREE, no-obligation exploratory chat.
Product of the Month
Reusable plastic storage boxes with reusable labels in different sizes and cool colors. Collapses flat for easy storage. $8.75 and up. Packaways.com.
The good physician treats the disease; the great physician treats the patient who has the disease. ~William Osler