Do you know what your medical record says about you? It can be easy to assume that we do, that what is contained there is just what we’ve spoken about to our doctors and appointments we’ve attended.
However, records are not always accurate, and it’s important to verify that your medical record really describes your medical history. You may find dangerous errors that could impact the care you receive.
How to correct your medical record
You are legally entitled to access to your medical record. For some healthcare providers, this is as easy as logging into a provided Patient Portal or similar online system. If this is not available through your provider, or you have questions about accessing it, you can simply ask them for access to your records.
If you find issues, you have the ability to submit requests for changes. Very Well Health has a handy guide for reviewing and correcting your medical record. The first step is contacting the hospital or healthcare provider who handles the record and asking if they have a specific form to submit correction requests, and if so, to provide it for you.
When writing your correction request, ensure that you are clear and detailed in exactly what needs to be corrected, what it should read, and in some cases, any relevant information on why the change is necessary. That last inclusion is important for complicated corrections. You can make a copy of any pages where changes need to be made and mark on those copies the specific areas of concern.
Your provider must respond to your request within 60 days, but may submit a 30-day extension to you in writing. They are not under obligation to make the requested changes, a rule set in place to prevent patients from removing valid information such as addiction. If a valid request is denied, you can submit a note contesting the information to your medical record or file a complaint with state and federal agencies.
The contents of your medical record can have a significant impact on the type of care you receive. CNN includes a number of examples of errors that can impact care, from simple contact information updates to false diagnoses and billing for tests that were never received. Major errors, like inaccurate diagnoses, can actually pose a direct threat to your health and well-being.
This could include:
Errors like this can result in medical malpractice, as a doctor may be doing everything appropriate for a condition that you do not have, leading to new problems.
If you have any questions about your legal rights concerning your medical record, or have suffered from mistakes in your medical record, contact us today and learn how we can help you.