As doctors scramble to convert their paper records to an electronic health record, many errors are surfacing. These will follow you from doctor to doctor, altering your diagnosis and treatments along with the possibility of life-threatening surgery!
A way to protect yourself is by periodically reviewing your records. By law, you have the right to review your medical chart and make corrections or amendments.
Key Chart Elements
There are certain entries into the chart that you will want to direct your attention to and if incorrect, change.
They include:
1. Contact information
- Phone number
- Address
- Emergency contact person and number
2. Diagnosis
3. Treatments done or treatment options offered
4. Lab results
5. X-ray reports
6. Specialists seen
7. Insurance and billing information
If amendments to your record are warranted, contact the medical office and ask the provider if there is a form they need to make the changes or if it can simply be done in a letter sent by fax, email or “snail mail”.
Make the correction to read exactly as you feel it should be and where it is located in the current record including the date of service. Make a copy for your records and have confirmation that this letter was sent.
Will Your Change Matter?
The practice or healthcare provider is required to take action on your request within 60 days. Although the doctor and practice is not required to make the alteration you requested, it most certainly will be done. After all, it benefits them as well as you to have accurate records.
If the providers feel there is no basis for your amendment and refuse to make the changes, they must notify you in writing. Should this occur, you may add a written disagreement which must be incorporated into your record.
The federal government provides a procedure for making a formal complaint on the U.S. Department of Health and Human Services website, for those who feel that privacy has been violated during an amendment request.
The Medical Information Bureau (MIB)
There is an organization called The Medical Information Bureau responsible for supplying information to health insurers, life insurers, and other entities which have interest in a combination of your health information and credit information.
To correct your MIB records, follow the procedure they have outlined on their website.
Just remember, it is up to you to perform due diligence…and why wouldn’t you? Your life can depend upon it!
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