Sloppy Medical Records

[LeeK]

Just curious to how many of you regularly get a copy of your medical records after each visit? I learned a lesson the hard way and request a copy after each visit so that I can review it for accuracy. This goes not only for back doctors, but family doctors and everyone else!

After I found a HUGE grieveous error that a Physician's Asst. made in my chart (from the first office I went to after the accident) I started requesting records from other doctors, even if unrelated. You would be really surprised by the sloppy errors that are made!

I had an appt. with a foot doctor. Glad I asked to review my chart at the time I checked out. He wrote in my "history" that I had previous back surgery in 2000(BEFORE the car accident--which I DID NOT) and that I was on some medication I had never heard of. I was pretty livid--these records were being subpeoned for the lawyers. I demanded an amendment to the record (and got it) but they acted annoyed--like I was over reacting. I won't go back to them.

The office that read my scan after the discogram wrote the wrong name of the ordering doctor down and the wrong disc that tested positive! When my doctor read the report with me for the first time, he was pretty p.o.ed. He said, "these people can't get anything right!"

I've found other inconsistencies as well but won't bog you down with the details. Just keep this in mind.

Offices can charge you a fee but so far, only one of my doctors has (incidently the one who made the HUGE error with the Phy. Asst) and it could be money well spent, depending upon your circumstances. I wish I had not been so naive and trusting about doctors and requested to see my records sooner with the Physician Asst. problem. By the time I saw the record and error, they claimed they "could not remember what was said" and refused to amend it.

[sahuaro]

Great advice, Lee! Having been through the personal injury suit to recover damages from a car accident, I am well aware how sloppy medical records are and how quick insurance company attornies are to seize on any inconsistency. I'm sure others here have experienced the same re medical records.

[spotty14]

I always get compies of my medical records and usually do it at the time I'm seeing a certain doctor or having procedures done. I have also found lost of inaccuracies documented from incorrect demographic information to the incorrect body part, incorrect dates, etc., The latest was on a MRI when the radiologist indicated that I had which I didn't have. My doctor requested the amendment for me. I also requested that my records be corrected and they were. Under HIPAA laws you can request either an addendum or an ammendment. The providers that get irritated shouldn't - sometimes it's the difference between insurance paying for treatment or not.

[LeeK]

Spotty,
How does the addendum work? Since they won't amend the record, does the addendum just note my complaint? I did write a detailed letter to the doctor outlining what was said--must it be a "formal" document? Is it too late? I think HIPAA went in effect after the error.

Every time I find an error in any kind of record, I show my lawyer. He is concerned but not surprised. He says he sees it "all the time" How scary is that!!!???

One dr I went to made it a practice to dictate his notes while you sat there at the end of the appt. That's never happened to me before...and I had to interrupt him several times to correct him and then stopped over minor details cuz he was getting annoyed with me. It is scary how wrong they can get some things and the worst part is...if you are in any type of legal proceedings and your doctor is deposed...they never remember anything independently from what they wrote down and most attorneys/judges and doctors take what's written down as gospel whether it's fair or not...so yes...get your records and review them!

[LeeK]

Wish I knew then what I know now! I hope my legal miseries will help someone avoid the same problems!!

[luvmysibe]

This is definitely sound advice that should be heeded. A while back we also talked about the importance of requesting copies of all of your records including films and digital records.