Written By: Lori Jusczak, Nurse Paralegal
As medical providers move toward the practice of maintaining electronic medical records, it is important to keep a few things in mind during this transition. Unfortunately, not all providers have the same level of proficiency with technology and this can create some problems with the accuracy of your records. During an average visit with your doctor, the quality of your medical records may not even register as important. Once the contents of those records become a deciding factor in your approval of benefits or insurance, it may be too late to think about it.
For example, many medical documentation programs automatically copy forward a “normal” health exam or even the last health exam. These systems are in place for the purpose of making things fast and easy for the provider. The expectation is that only what is different would need to be edited. However, when you come for a “discussion only” type visit and a full examination is not performed your medical record may very well have stored a “normal” health exam or a copy of a previous health exam on that date. Imagine a copy forward that you have been mountain biking while you are collecting from Worker’s Compensation for a back or leg injury. This could become a significant issue if you end up denied payment on a Workers’ Compensation or Social Security claim based on these types of errors. Many providers are not even aware that any information is stored in the physical assessment section of the medical record if they do not open it.
According to HIPAA (Health Insurance Portability and Accountability Act of 1996), patients have a right to access their health records and I would recommend that patients’ access that right to review their medical records periodically. It is possible for your health care provider to correct errors made in electronic records but this can be time consuming, and even appear suspicious when it is done over a long period of time. It is important to be an informed consumer in all areas, health care included!