Three ways to protect yourself from medical record mistakes

November 10, 2020 in Health Risk Management  •  By Miles Varn, MD
medical record

In a perfect world, your electronic medical record would bring together your medical information from all the healthcare providers you see into a single, comprehensive record that could be easily accessed by any provider anywhere in the world with your permission. This information could reduce your risk of medical errors, duplicate testing, and inappropriate treatment. It could also be lifesaving if a medical emergency caused you to be unable to answers questions and share information. But, of course, the world isn’t perfect and neither are electronic medical records.

Errors in electronic medical records and systems occur more frequently than you may think. A Kaiser Family Foundation survey found that one in five people surveyed reported an error in their electronic medical record. Those errors included incorrect personal information and incorrect information about their medical history, test results, and prescriptions.

 There are a number of different causes for these errors, including:

  • Healthcare provider mistakes (inputting incorrect or incomplete information, cutting and pasting incorrect information, identifying the patient incorrectly)
  • Electronic health record (EHR) systems that do not communicate with each other, leading to fragmented and incomplete records
  • EHR system failures
  • Lags in data, such as test results, new prescriptions, and hospitalizations, being updated

Take these steps to lower the risk of errors in your electronic medical record

There are several things you can do to reduce the risk of medical mistakes related to problems with electronic medical records:

  • Be a proactive partner in your care. Regularly request a copy of your records from all healthcare providers you see, including primary care, specialists, urgent care, hospitals, and outpatient or ambulatory care centers. Start by checking to make sure that all the basic information is correct (name, address, date of birth, Social Security number, health insurance information, emergency contacts). Then review your medical history (allergies, symptoms reported, diagnoses, prescription medications, diagnostic test results, medical and surgical procedures performed). Make sure the information is current. For example, does your record still list medications you no longer take or requests for tests you’ve already completed?
  • Have a medical home. Having one healthcare provider who acts as your point person can help ensure not only that the care you receive is coordinated amongst providers but can also help keep your medical records consolidated. Choose a provider you see regularly, usually your primary care provider, to act as your medical home. You’ll need to let your provider know what other doctors you see and have those providers share your records and test results with your medical home.
  • If you find an error, get it corrected. If you do spot a mistake in your medical record, contact the provider, and ask what the practice’s or facility’s procedure is for making a change to your record. Some providers use a form or you can write a letter that outlines the error, provides the correct information, and includes a copy of the page of the record with the error highlighted. Providers have 60 days to correct an error, although they can request an extension. Your provider should send you a notification that the error has been corrected. After the 60-day period, request a corrected copy of your record and review it. If the provider does not agree that there is an error, he or she should send you a denial notice, explaining why the correction is not being made. You can respond in writing, explaining why you don’t agree with the decision and a copy of your letter should be included in your record.