I guess it could have been worse: My medical record could have listed a terminal illness. Instead, while perusing my electronic medical file recently, I found a note that totally stumped me: “multigravida.”
Clicking on this record brought up the following message: “Twins, triplets, multiple births. If you are pregnant with more than one baby, you are far from alone.” Huh, what? I haven’t been pregnant with one baby, let alone multiples. How could such an erroneous term — it’s a technical term for a pregnant woman who has been pregnant one or more times previously — end up on my medical record?
It’s not uncommon for medical records to contain errors, says Trisha Torrey, founder of the Alliance for Professional Health Advocates. Torrey recommends that all patients take the time to closely examine their medical records. Doing so paid huge dividends for Torrey, when she discovered an error that had led her to become wrongly diagnosed with cancer. Had she not been so diligent about scrutinizing her records, she would have undergone chemotherapy and other cancer treatments that she never needed.
Under the federal Health Insurance Portability and Accountability Act of 1996, you have a right to view and obtain a copy of your medical record, Rachel Seeger, a spokeswoman for the U.S. Department of Health and Human Services’ Office for Civil Rights, said in an e-mailed statement. If you find inaccuracies, HIPAA gives you the right to have these errors corrected.
If your doctor uses an electronic patient portal, as mine does, you may be able to look at your records from home, without charge. If your provider can’t share your records electronically, you may have to pay for them. Under HIPAA, health plans and health-care providers are allowed to charge a “reasonable” fee for copying and mailing the records, Seeger said. “Reasonable” isn’t legally defined, however.
While the transition from paper to electronic records makes it simpler for patients to view their records, it has also made it easy to introduce mistakes into the records due to data input or transcription errors, and this is especially true when paper records are turned into electronic ones, Torrey says. “Sometimes older paper records are scanned into an optical character recognition program and they come out wrong.”
A 2012 study examined more than 300 reports of problems involving faulty records at Pennsylvania hospitals and found that errors in electronic medical records could become amplified when the inaccurate information was shared with other providers — for instance, when it was transmitted to pharmacists who then prescribed the wrong medication.
When I discovered the error in my record, I sent a message to my doctor’s office asking about the discrepancy. The practice assured me that “on our side of the chart, it lists 0 previous pregnancies. Sorry for the confusion.” I went back to my chart and saw that it still listed “multigravida” in the section marked “past medical history.”
So would it be worth the hassle to keep insisting that my doctor’s office correct this mistake?
Absolutely, says Melody McCloud, an obstetrician-gynecologist and the medical director of Atlanta Women’s Health Care.
You also should check your medical record to ensure that you and your insurance company are being properly billed.
Take a close look at the notes and billing records associated with your visits to make sure that you received the care it says you did, advises Torrey. The Affordable Care Act mandates that certain types of preventive care, such as Pap tests and other preventive visits, don’t carry a co-pay, but if the office tacks on a service that you didn’t receive, you may be billed extra, she says.
When I switched to my current doctor, I requested a copy of my medical record from my previous physician. I was surprised to see that the doctor’s notes for my last visit noted that we “discussed stress management, healthy diet, health weight, and exercise.” And more: “sunscreen use, seatbelt use and basic healthy lifestyle choices” (whatever those are). I am quite certain that she never discussed these issues with me, nor had she raised them at previous appointments, which contained the exact same sentences in their notes.
Given that the wording about all those things we (didn’t) discuss was identical, I assumed that this must be some sort of boilerplate note that this doctor puts in all of her records. But why say we talked about something if we didn’t? Usually mistakes like these happen when a doctor is just checking boxes on a computer or adding automatic entries to your record, rather than writing a narrative account of the visit, McCloud says.
Listing services that I didn’t receive isn’t just dishonest, in some cases it may also represent fraud, Torrey says, if it means the office can use a billing code that leads to additional reimbursement. If you find notes about a service or discussion that didn’t actually take place, you should also take a closer look at your billing record to see if you were charged for something you didn’t receive, she says.
If the discrepancy results in a billing error, you should contact your insurance company. Even if it doesn’t, you can insist on a correction. When you and your provider disagree about the accuracy of the information in your record, HIPAA gives you the right to have a statement about your disagreement added to the file.
Your medical record is your health-care providers’ reference book for your health, so the importance of making sure it’s accurate can’t be overstated, McCloud says. What’s in the record may dictate the treatments and testing you receive and the advice your doctor orders.
“It’s your story,” McCloud says, “and so it can’t be fiction.”