Have you reviewed your medical records? You should

November 13, 2018 in Health Risk Management
medical records review

Thanks to HIPAA, you have the right to get a copy of your medical records and review them. There’s a good reason to take the time to read over your records in detail. A study published in BMJ Quality and Safety found that 29% of the study participants who reviewed their doctors’ visit notes found information they believed was incorrect.

OpenNotes, a non-profit that advocates for the sharing of medical visit notes with patients, says nearly 29 million Americans and Canadians currently have online access to their notes. While checking these records for accuracy is important and can lower your risk of misdiagnosis, duplicate testing and procedures, and inappropriate care, and even provide evidence of medical identity theft, there are a number of other important reasons you should review this information regularly.

  • Information from previous visits can help you prepare for an upcoming appointment. Reviewing past notes can help you figure out what questions you’d like to ask your doctor or issues you’d like to revisit during your next appointment. For example, if your doctor recommended weight loss as a first step to control high cholesterol, you can ask if your levels have improved enough or if you should consider cholesterol-lowering medication.
  • Notes can help make sure you and your doctor are on the same page. What you heard at your appointment and what your doctor meant to convey may not be the same. Reviewing the information in your medical records and visit notes gives you the chance to read what your doctor said at a time when you’re less likely to be anxious, distracted, or feel rushed. In addition, if you’ve received a serious diagnosis, you may not remember everything that was said at your appointment, so reviewing the notes gives you the opportunity to better understand your diagnosis and treatment plan.
  • Reviewing your records gives you the chance to clear up misunderstandings. If your doctor used terminology that you didn’t understand at your visit, you can use your notes to identify any terms or information you didn’t understand and get in touch with your doctor to ask for clarification in plain English.
  • If you forgot to mention something, now’s the chance to get it added to your record. There’s a lot going on at a doctor’s appointment and even the well-prepared patient can forget to share important information. After reviewing your medical records, if you realize you didn’t share information such as family history, allergies, previous diagnosis or treatment, current medications, or symptoms you’ve been experiencing, contact your doctor and provide the missing information so your doctor can develop a personalized risk management plan for you.
  • Access to your medical records allows you to share information with all your doctors: If you see more than one doctor, reviewing your visit notes and sharing them with all the doctors who are treating you can be another way to lower your risk of overtreatment, medication interactions, and duplicate testing.
  • Checking your records can help prevent billing errors. When you review your visit notes, make sure that the care that’s recorded in your record matches the care you received. For example, if the note says you underwent an EKG but your doctor didn’t perform that test, contact the office to correct the error so you and your insurance carrier are billed only for the care you received.