In a recent visit, Janice and her doctor discussed whether it would be medically useful for Janice to have an indoor swimming pool at her home. Later, she saw a copy of her medical records from that visit. Here is how that conversation is reported: "(The patient) would like to have a laparoscopic cholecystectomy in her house."
A laparoscopic cholecystectomy is an operation to remove a gall bladder.
Her doctor is outstanding. He is keenly intelligent, and has common sense that is both rare and wonderful. She is very glad to be his patient. But her gallbladder is in excellent condition, and they certainly never discussed having it removed in her house.
When she called the doctor's office, the doctor's assistant was completely unapologetic about the error. Janice and the doctor had discussed a "lap pool." The first three letters of that phrase are the same as the first three letters of "laparoscopic cholecystectomy." The doctor's office uses a computer program to transcribe his notes, and it includes a "type ahead" feature - when the first few letters of a word or phrase are known, it guesses what the rest will be, based on terms commonly used in the doctor's practice.
Evidently, more people talk to the doctor about having their gallbladders out than talk to him about swimming. The doctor's assistant explained that it was completely logical that the transcription said that they had discussed Janice's having a laparoscopic cholecystectomy in her house.
Janice's experience with her medical records is not unusual. One study described in the Journal of the American Medical Informatics Association found that 25 percent of patients reported finding errors in their medical records. Medical records expert Joy Pritts in Georgetown University's Health Policy Institute was quoted as saying, "They happen all the time."
Examples of other errors in medical records include:
- Typing a diagnosis or treatment code number incorrectly, so that entirely wrong diagnoses and treatments are reported.
- Entering one patient's data into another patient's chart.
- Reporting that the patient has had a disease or treatment that he hasn't had (even without typing codes incorrectly).
- Noting that the patient reported a symptom that in fact he did not have and did not mention.
- Reporting that the patient is currently being treated for a condition he hasn't had - nor has been treated for - in decades.
- Identifying the wrong side of the body as the site of a problem -- saying that the left wrist was broken when it was the right wrist, for instance.
- Saying that the patient has agreed to a course of action when the patient did not.
- Making erroneous assumptions about cause and effect. For example, a new patient reported taking a certain allergy medicine. The doctor wrote down that the patient reported having allergies. In fact, the patient did not have allergies. Her former doctor had prescribed the drug to treat an inner ear balance problem.
Mistakes in your medical records can lead your doctor to misdiagnose you, to order unnecessary tests for you, to prescribe treatments that are inappropriate for you, and to ignore problems that are important to you.
In short, your doctor may end up going down the wrong path entirely as a result of errors in your medical records. At the same time, you are probably the only one who can tell if the records are wrong. Despite these facts -- and some encouraging shifts in attitude over time -- a recent study by the Markle Foundation found that today a third of doctors still do not agree that patients should be able to have copies of their personal health information.
Even if your records are perfectly accurate, you may find that knowing what is in them can make a big difference to your health. Many readers have told me the information they found in their medical records surprised them. In a number of cases, the medical records contained information, which, if acted upon, would have saved them months or years of misery. But they never found out about it until they got their records much later.
What can you do to benefit from knowing what's in your doctors' files and to find out if they contain errors that could harm you? The first step is to understand your rights to your medical records.
You have a legal right in all 50 states to see the content of your medical records. (In some cases, exceptions apply to records related to mental illness or to alcohol or drug abuse.) If you know what procedures to follow, getting your records can be fairly straightforward.
The exact steps you need to take are different in every state. If you have lived in more than one state, you may need to understand the rules in different states.
Georgetown University has established a Center on Medical Record Rights and Privacy. The Center has created a brochure for each state that explains very clearly how to go about getting your medical records. Each brochure title is, "Your Medical Record Rights in (name of state)." You can download these at no charge from http://ihcrp.georgetown.edu/privacy/records.html, or search online for Georgetown medical record rights.
In Arizona, health care providers generally are required to keep their records about you for six years after they last treat you. If they have your records, they are usually expected to provide a copy to you within 30 days of your request. They are allowed to charge you for the cost to photocopy and mail the records to you.
Future columns will discuss what medical records to ask for, how to make the request, what to do once you've asked for your records, and how to correct any errors you find.