How to Review Your Medical Records for Errors

Fixing mistakes can have an impact on your diagnosis and treatment

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Do you know how to review your medical records for errors? The use of electronic medical record keeping allows the instant transfer of medical information between doctors, hospitals, testing centers, and other facilities. This easy flow of information can perpetuate any errors entered by one provider. It becomes imperative that patients keep track of those records and correct any errors that occur

Which Medical Records Need Review?

  • Doctor's and other provider's notes about your visits
  • Medical test results
  • Records kept by any testing centers, hospitals, or other facilities you visit
  • Information from the Medical Information Bureau (if such records exist)
  • Insurance billings and codes

It may be difficult to obtain all these records, but it's definitely worth the trouble so you can correct the information.

Discovering Errors In Your Medical Records

An example is a woman who visited her primary care physician because of a golf-ball-sized lump on her torso. She was asked when it appeared and whether it was painful. Although she said it wasn't painful, it was recorded as painful. This could have influenced the determination of whether the lump was cancerous or not. By reviewing her records and correcting the mistake before it was used in the diagnosis by the pathologist and oncologist, she might reduce the chance of a misdiagnosis.

Types of Information That Should Be Corrected in Your Medical Record

You will want to correct any error that can have an impact on your future dealings with the provider or insurer. It may have an impact on your current treatment, insurance, or future health care. Errors can even lead to medical identity theft.

Check your identification information to make sure your name, address, phone number, and other data are correct. Report any discrepancies to the person who made the error. Ask her to correct the notations while you wait.

Review any notes taken about your meetings to be sure your symptoms and test results have been recorded correctly. Again, report errors to the person who made them, and ask her to make the correction immediately. If you don't see her make the correction, then follow up later to be sure it has been taken care of, or follow the more formal procedure outlined by HIPAA laws.

Health insurance billing needs to align with the services you received. You'll do this after you receive the billing notice from the insurance company. Line up the services they report with the services on the receipt given to you by the doctor's or facility's office. If they are incorrect, report the error to your insurer.

What Should You Do If Medical Record Errors Are Discovered?

There are specific steps to take to make those corrections. Contact the provider's or payer's office to ask if they have a form they require for making amendments to your medical records. If so, ask them to email, fax, or mail a copy to you.

Information from the Medical Information Bureau gets corrected through its own procedure.

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