Edith’s records in the nursing home said that she was in a wheelchair and needed two aides in order to engage in any activities, such as getting dressed or eating. That had been true in the first week or two after she’d been discharged from the hospital, but it hadn’t been true since then. It was now three months since Edith had landed in the nursing home, but her daughter Alice found that the records still said that she couldn’t function at all on her own.
What difference did it make? Nights and weekends, the nursing home tended to have transient caretakers. They might only be there for a few days, sent from a temporary help agency. If they relied on the records, they would constantly be telling Edith to sit down and wait for help, interfering with her every move and seriously upsetting her, night after night, weekend after weekend. What kind of life is that? Alice got the staff to correct the records, buying her mother some peace, independence, and privacy.
Your medical records might have errors in them, too. A previous column explained how to get your medical records (see http://hpi.georgetown.edu/privacy/records.html for specific instructions by state). Once you have them, it’s useful to check them for mistakes. To do that, it helps to understand what constitutes an error and what doesn’t. Examples of entries in your medical records that would not be considered mistakes:
- The doctor’s diagnoses with which you disagree: “This patient is suffering from depression.”
- The doctor’s opinions that offend you: “This patient needs to lose weight and stop stressing so much about work.”
- The doctor’s data: for example, if his office scale says that you weigh five pounds more than your scale at home says, that does not count as an error.
Examples of entries in your medical records that would, in fact, be considered mistakes:
- “The patient has had his left leg amputated,” when he hasn’t.
- “The patient was treated for 10 years for depression,” when the patient was treated for two years.
- “The patient complained of severe abdominal pain,” when the patient never mentioned pain and didn’t have any.
- “The patient reports improvement with this treatment,” when the patient said that she got worse.
- “The patient wants to have cosmetic surgery,” when the patient sought treatment to fix severe damage from an automobile accident.
- “The patient will start taking Drug X,” when the patient did not agree to take Drug X and did not walk out of the office with a prescription for Drug X.
If you find errors in your medical records -- a common situation -- it may be important to correct the errors to prevent doctors who you see in the future from drawing completely erroneous conclusions about you and your medical conditions and needs.
See http://hpi.georgetown.edu/privacy/records.html for details about how to correct your medical records in each state in which those records were created. Generally, the following guidelines will apply.
First, the only doctor who can correct an error in your records is the one who created it. If Doctor A created medical records with an error in them and then sent copies of your file to Doctors B, C and D, there is no point in asking Doctor B, C, or D to correct the record. They can’t touch it. It will be necessary to figure out that the error came from Doctor A, and ask him to address it.
Second, you might be surprised to learn that no one will ever remove an erroneous entry from your records. For legal reasons, once a record is created, it is as if it is cast in stone. The best that can be done is to amend your record. When you amend your record, a statement is added to your record explaining what is wrong in the record and what the correct information is.
Third, to amend your record, you will need to put your request in writing.
Fourth, when you write your request, it is best to write the very language that you want your doctor to put into the medical record. Of course, it needs to be reasonable and appropriate to the situation. For example, it won’t help to write, “You didn’t listen to me at all the last time I was in. You need to change my medical record and take back those things you said I told you, because I didn’t say any of that.”
It is more useful to write, “I ask that you amend your notes from my visit to you on September 23th, 2011. Your notes say that I said that I had insomnia, stomach aches and diarrhea every day for the preceding two months. Please add the following statement to my records: “The patient notes that she did not say that she had had insomnia, a stomach ache and diarrhea every day for the preceding two months. She notes that she said that she had had these symptoms for a total of two days in the preceding month and that they resolved on their own without any treatment.”
Fifth, it is not enough to ask that your records be amended simply because they are wrong. It is typically required that you explain why you believe the error needs to be addressed.
In this example, for instance, you might say, “I would like you to amend my record because I am concerned that other doctors who see those records in the future may conclude that I have some serious chronic gastrointestinal problem that needs treatment -- when the symptoms I had were short-lived and went away on their own.”
Steps to amend your records are similar to steps to obtain your records:
- Call the doctor’s office and ask if they have a form for you to use to request an amendment to your records. If they say yes, use their form.
- If they say no, ask what information they need from you in a letter.
- At a minimum, include in your letter:
- The date
- Your name and contact information
- The doctor’s name and mailing address
- Your social security number, or your medical record number if they use one
- Your date of birth
- The fact that you are requesting that they amend your medical records
- The date of the error, the type of record that contains the error (for example, doctor’s notes vs. lab test), and a description of the error
- The statement you have crafted that you want them to add to the record
- Your signature
Once your doctor has amended your records, you are free to ask him to send copies of the amended records to specific doctors you name who you believe received the erroneous information.