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Do you have inaccurate or outdated information in your medical records?

Errors, misdiagnoses, and former diagnoses in your records can have far reaching consequences on your health and well being.

Right now in the United States, only some health care professionals have access to your medical records. One provision of the Affordable Care Act was to require that any health system that accepts coverage such as Medicare and Medicaid transition to the use of electronic medical records.

Typically if you see a doctor at one health care system, only providers in that system will be able to see your records, unless you voluntarily share them outside of that system. If Pleasant County Health System has your records, all providers associated with Pleasant County can see your records, though they should only be looking if they have good reason. If you share records from Pleasant County Health System with a doctor who works in Happy Basin Health System, all of Happy Basin’s staff will have access to your records.

But in the future this will change. The goal in health care information technology is something called interoperability, which means your records from any health system will be visible at any other place you seek treatment. Explore the US government’s Interoperability Roadmap here. Eventually interoperability will exist worldwide.

Isn’t that a good thing?

Yes…well, ideally it is.

If all of your records are accurate, this sharing helps make sure the care you get at any facility takes into consideration all the conditions you have. If the new doctor you are visiting while in another town needs to see the lab results or an allergy list from your primary care provider, she can see them. That goes a long way to prevent retesting and guesswork, especially in an emergency situation.

But if your records contain errors, the opposite can happen.

Say your medical record from Pleasant County Health reports that you have bipolar disorder. You may not actually have bipolar disorder, but you once saw a psychiatrist (doctor #1) at Pleasant County who thought you did. Doctor #1 put bipolar disorder in your medical records. When you see doctor #2 at Pleasant County for fatigue, weakness and muscle aches Dr. #2 may be short on time or competence and assume your fatigue, weakness and muscle aches must be associated with a depressive episode from your bipolar disorder. Dr. #2 may miss a problem with your thyroid in part because of Dr. #1’s diagnostic error. We all hope that doctors like # 2 don’t fall prey to bias, but hope won’t get you good health care.

Does this really happen? Unfortunately, yes. Here’s a piece from the New York Times about something called diagnostic overshadowing. Diagnostic overshadowing is the term used for when a patient’s coexisting condition is believed to result from their mental status, and a thorough investigation into the coexisting condition isn’t made because of the assumption that patient’s problem is psychiatric, rather than physical.

Uh oh. What can I do?

You can write to the facility that holds your records and ask to have them changed or amended. Provide as much evidence as you can to support your case. The facility must review your request and respond.

In the United States, the department of Health and Human Services oversees administration of HIPAA law, which governs the handling of your medical records. If you see an error in your records; the law provides for you request an amendment to your health record or information. Below is a part of the statute that governs amendments to health records.

Visit the Health and Human Services website for more information. The information below is from that source.

§ 164.526 Amendment of protected health information.

(a) Standard: Right to amend.

(1) Right to amend. An individual has the right to have a covered entity amend protected health information or a record about the individual in a designated record set for as long as the protected health information is maintained in the designated record set.

(2) Denial of amendment. A covered entity may deny an individual’s request for amendment, if it determines that the protected health information or record that is the subject of the request:

(i) Was not created by the covered entity, unless the individual provides a reasonable basis to believe that the originator of protected health information is no longer available to act on the requested amendment;

(ii) Is not part of the designated record set;

(iii) Would not be available for inspection under§ 164.524; or

(iv) Is accurate and complete.

(b) Implementation specifications: Requests for amendment and timely action.

(1) Individual’s request for amendment. The covered entity must permit an individual to request that the covered entity amend the protected health information maintained in the designated record set. The covered entity may require individuals to make requests for amendment in writing and to provide a reason to support a requested amendment, provided that it informs individuals in advance of such requirements.

(2) Timely action by the covered entity.

(i) The covered entity must act on the individual’s request for an amendment no later than 60 days after receipt of such a request, as follows.

(A) If the covered entity grants the requested amendment, in whole or in part, it must take the actions required by paragraphs (c)(1) and (2) of this section.

(B) If the covered entity denies the requested amendment, in whole or in part, it must provide the individual with a written denial, in accordance with paragraph (d)(1) of this section.

(ii) If the covered entity is unable to act on the amendment within the time required by paragraph (b)(2)(i) of this section, the covered entity may extend the time for such action by no more than 30 days, provided that:

(A) The covered entity, within the time limit set by paragraph (b)(2)(i) of this section, provides the individual with a written statement of the reasons for the delay and the date by which the covered entity will complete its action on the request; and

(B) The covered entity may have only one such extension of time for action on a request for an amendment.

So find out what’s in your medical records and request to have corrections made if you find errors. You can get your records by requesting them from the provider’s office or sometimes from a medical records department affiliated with your provider’s office. In many cases, records are available online through patient portals.

 

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<p>Twilah H is a recovering patient. She studied Philosophy with a concentration in ethics at the University of Kansas. Through writing, meditation, relationship building, and quilt creation she has found a place of peace.</p>

2 thoughts on “What Your Records Say Can Hurt You

  1. I’m a chronic pain patient. I read to help my pain (I read comforting books that I know well to take my mind off the pain and to help meditate…).

    In my chart, a doctor noted: Patient says she is in severe pain, but is reading a book. Therefore, she can not be in pain.

  2. Deena, I am sorry that you live with chronic pain. I am sure that most people who don’t have chronic pain (including myself) do not have the slightest clue how that affects a person on a day to day, moment to moment basis. That you have found a coping mechanism in reading is wonderful. But yes, it is ridiculous but absolutely typical, that a physician would use your healthy coping mechanism of reading to undermine the validity of your complaint.

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