When Was the Last Time You Read Your Medical Record?

Julie Shenkman
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American law stipulates that patients have a right to view their own medical records at any time. The difficulty is that ordinary people may not be able to interpret what a health care professional writes onto someone's chart. Even computerized records can be confusing to patients. What's worse is that someone's vital records do not give a doctor the patient's story.

Dr. Dhruv Khullar, a resident physician of Massachusetts General Hospital and Harvard Medical School, writes for the New York Times that he discovered relying on a person's medical records is a flawed approach. On several occasions, he went through a patient's records to ascertain someone's health history. What he found were several inaccuracies.

Khullar asked one person about the surgery she was about to have next week. The patient told him the surgery was three months ago. Another person's chart indicated diabetes, but that patient insisted she didn't have the metabolic disorder. These instances show the importance of getting a patient's story from firsthand knowledge rather than going through someone's records.

Studies seem to back up the doctor's experiences. One review states that just 5 percent of electronic medical records accurately listed the medications that patients took. A second study says that 43 percent of medications listed on someone's record are incorrect. In many cases, allergies and adverse drug reactions do not show up in a patient's records at all. Lawsuits stemming from these issues doubled from 2013 to 2014, and the litigation may become more frequent before health care providers solve these problems.

Health information technology, one of the principles behind the Affordable Care Act, is supposed to alleviate the problem of inaccurate medical records. Technicians make sure electronic records show the correct information, and that codes are properly input from paperwork. Hiring more technicians may help the health care industry, but there's another problem with that idea.

Patient notes automatically go into a computer file. Doctors frequently copy and paste the notes to quickly upload the data. If the patient notes aren't right, there's a problem as misinformation spreads from one computer record to another.

What can be done? Doctors should start encouraging patients to read their own medical records. This, in turn, could encourage doctors to make better notes that their patients can read. A study finds that around 20 percent of patients view their own records. Out of those that do access electronic records, 80 percent find them helpful. Much like talking to person to get the right information, sometimes a patient knows best when it comes to viewing a record of someone's health history.

Thanks to information technology and Internet connections, patients should have access to their medical records at any given moment. With the help of the health care industry, Americans should be able to help their doctors maintain accurate data.

Photo courtesy of photostock at FreeDigitalPhotos.net


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  • elizabeth d.
    elizabeth d.

    they don't let you read everything

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