Health care providers use a variety of methods to keep their records up to date. Paper forms, kiosks, tablets and online portals are all commonly used.
Though the potential for medical records errors has always existed, the increased use of technology combined with fewer personal interactions between patients and office staff may contribute to inaccuracies in patient records.
Common mistakes
Some of the most common medical records mistakes involve:
- Data entry errors: Information may be entered incorrectly into electronic health records (EHRs) or paper records during the registration process.
- Miscommunication: Details provided by patients or healthcare providers during consultations or visits may be misunderstood or recorded inaccurately.
- Identity mix-ups: Similar names or identifiers could lead to confusion, resulting in medical information being attributed to the wrong individual. If a child or spouse is completing a form for someone else, they might accidentally put their own information.
- Outdated information: Changes in personal information, such as address, phone number or insurance details, may not always be updated promptly in medical records.
- Incomplete records: Certain information may be omitted unintentionally, affecting the completeness and accuracy of the medical history.
Patients and their families can take more responsibility for the accuracy of their records, and mistakes can be corrected. Keep in mind: it’s better to catch and correct errors quickly to ensure accurate diagnosis, treatment and billing.
Review and follow up
If you suspect that there is incorrect information in your medical records, here are some steps you can take to address them:
- Review your records: Obtain a copy of your medical records from your health care provider or hospital and review them carefully. If possible, have someone you trust go over the records with you.
- Identify errors: Look for inaccuracies in personal information (e.g., name, date of birth), medical history, medications, allergies, test results or treatment plans.
- Contact your health care provider: Inform your health care provider or the facility where the error occurred about the inaccuracies. They may have a specific process for correcting errors in medical records.
- Provide documentation: If possible, provide documentation (such as identification cards or official documents) to support the correction of personal information.
- Follow up: Follow up with your health care provider to ensure that corrections are made and updated records are accurate.
- Request amendments: Under the Health Insurance Portability and Accountability Act (HIPAA), you have the right to request amendments to your medical records if inaccuracies are not resolved satisfactorily.
Ensuring the accuracy of your medical records takes some extra time and effort, but it is essential for receiving appropriate health care treatment and avoiding potential complications that may arise from incorrect information.
Click below to read one family’s fight to correct their mother’s medical records.
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