Older adults have cause to be careful about what’s in their medical records. Although definitive data aren’t available, the Office of the National Coordinator for Health Information Technology estimates that nearly 1 in 10 people who access records online end up requesting that they be corrected for a variety of reasons.
In the worst-case scenario, an incorrect diagnosis, scan or lab result may have been inserted into a record, raising the possibility of inappropriate medical evaluation or treatment.
Omissions from medical records—allergies that aren’t noted, lab results that aren’t recorded, medications that aren’t listed—can be equally devastating.
Susan Sheridan discovered this nearly 20 years ago after her husband, Pat, had surgery to remove a mass in his neck. A hospital pathology report identified synovial cell sarcoma, a type of cancer, but somehow the report didn’t reach his neurosurgeon. Instead, the surgeon reassured the couple that the tumor was benign.
Six months later, when Pat returned to the hospital in distress, this error of omission was discovered. By then, Pat’s untreated cancer had metastasized to his spinal canal. He died 2½ years later.
“I tell people, ‘Collect all your medical records, no matter what’ so you can ask all kinds of questions and be on the alert for errors,” said Sheridan, director of patient engagement with the Society to Improve Diagnosis in Medicine.
In less dire scenarios, a patient’s name, address, phone number, or personal contacts may be incorrect, making it difficult to reach someone in the event of an emergency or causing a bill to be sent to the wrong location. Or, your family history may not be conveyed accurately. Or, you may not have received a service recorded in your record—for instance, a stress test—and want to contest the bill.
Dave deBronkart, a 68-year-old cancer survivor and patient activist, recounts mistakes he and his family have experienced. Once, he checked a radiology report through a Boston hospital’s patient portal. It had his name on it but identified him as a 53-year-old woman.
In another instance, the records that accompanied deBronkart’s mother to a rehabilitation center after a hip replacement incorrectly identified her as having an underactive thyroid when in fact she had an overactive thyroid.
A simple error such as a wrong phone number can be corrected by drawing a thin line through the material and writing a suggested change in the margins or making an electronic note. A more complicated error such as incorrect description of your symptoms or a diagnosis that you’re contesting may require a brief statement from you explaining what material in the record is wrong, why and how it should be altered.
Physicians and hospitals are required to respond in writing within 60 days, with the possibility of a 30-day extension. (Some states set shorter deadlines.) But medical providers are not obligated to accept your request. If you receive a rejection, you have the right to add another statement contesting this decision to your medical record. You can also file a complaint with the government office that oversees HIPAA or a state agency that licenses physicians.