What’s In Your Medical Records?

Do you know what’s in your medical records? Knowing what is in your records can play a big part in not only your future treatment but can also give you the information you need to ask the right questions of your doctor, which believe it or not, can lead to critical testing and proper treatment for many conditions. Every patient has a right to know what is in their medical records and dispute it if necessary.

In the past few months I have heard from many patients who have horror stories to tell about getting copies of their medical records and being shocked to read what their doctors put in their files. Remember, your medical records are much like your credit history and follow you from now until who knows when. All future physicians will seek copies of your current medical records, so you should guard them and ensure accuracy with vigilance.

Perhaps it is the nature of the lupus and its difficulty in diagnosing that leads to the erroneous information that is being placed in files. Or perhaps it is put there by physicians who are not specialists in the diagnosis and treatment of lupus who put incorrect information in a patients file. It doesn’t really matter why, it only matters that it is there and it can harm you and your future treatment for not only lupus, but for many other illnesses.

One particular patient was beyond shock when she read in her medical records that she had been diagnosed with a psychiatric disorder. This was only discovered when she finally read her records and the physician notes. It was the notes that disclosed this fact. She took immediate action to correct this unsubstantiated diagnosis. She had a letter written by her current rheumatologist and had it sent to be included in the records of the physician who put the “psychiatric” note in her file.

Another patient, who had not yet been given a definitive diagnosis, requested a copy of her medical records because her long time physician was closing his practice. It was only then that she found notes stating that her rheumatologist wrote a letter to her internist stating things that were totally wrong and that he had run tests that had never been done. This particular patient had been treated by the rheumatologist for over 10 years, yet the rheumatologist stated in his letter that the patient had only spoke of certain symptoms in the past 2 years. None of these errors would have been noted or corrected if the patient had not reviewed her medical records.

The last patient I will speak about was gathering and reviewing her records before she was sent to a tertiary treatment center. Among the records were 3 EKG’s all from the same date. On the top of the EKG’s it was noted that the patient had had a previous infarct, which means a previous heart attack. The patient was not aware of this so took copies of the EKG’s to her physician and asked for an explanation. Her current physician did another EKG to verify the results, which were once again abnormal. Further tests were ordered. The results were conclusive that the patient has limited blood flow to her heart and was scheduled for additional testing and treatment. In this particular case it is unknown if the abnormal EKG results would have been acted upon without the urging of the patient. In essence, this patient may have saved her own life. Limited blood flow to the heart will eventually lead to a heart attack which the patient may or may not have survived. They say that a little knowledge is a dangerous thing. In this case, limited knowledge and the desire to know more along with the willingness to ask questions really benefitted the patient.

These are just 3 of the many cases involving medical records and the importance of knowing what is in them. They are your records. It is your health. You need to stay aware of what is in them, and be sure to correct errors, ask questions, and know that ultimately you are the one who will be affected by what is written and stored in your medical file.

From the Life and Mind of
Wanda M. Argersinger, Executive Director
The Lupus Support Network
All Rights Reserved 2009

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