RECENTLY MY PRIMARY CARE PHYSICIAN (PCP) had to give his clearance for minor (cataract) surgery.
Since I have no confidence in office-to-office communications - messages are sent but never read - I asked for, and received, a copy of the clearance.
In the 7-page document I found 7 inaccuracies.
GRANTED, MOST of the errors were not what I would consider "critical," but I'm not a doctor and I don't play one on tv.
Still, there were too many incorrect statements.
Years ago, when AvMed dropped my long-time PCP, I asked for my medical records to hand carry to my next PCP.
Since I had been with this PCP for some time, the package was fairly thick.
As the information was about me, I started to go through the documentation page-by-page.
As I did, I found mistakes "page-by-page."
IT IS YOUR RIGHT
Patients have a right - and, frankly, I think an obligation - to check their own medical records. Most practitioners willingly provide copies of the patient's file upon request, albeit some may want to charge to make copies. (The alternative is to sit in the office waiting area and review the document.)
According to the American Health Information Management Association (AHIMA) the patient may have to complete an authorization form.
- The basic process for requesting a medical record is similar across states and provider types. Whether requesting your personal medical records from a doctor’s office or a hospital, in Hawaii or Ohio, the federal law known as HIPAA applies. HIPAA entitles every person the right to access his or her medical records, receive copies of them, and request amendments to them.
State laws, however, can add variations to the exact process for requesting records and how much facilities can charge for fulfilling them.
In addition, individual doctors’ offices and hospitals may have their own policies. These cannot contradict federal and state law, but they can add variation in the request process between facilities.
HIPAA - Health Insurance Portability and Accountability Act of 1996 a/k/a Pub.L. 104–191, 110 Stat. 1936 - is a Federal law that can be "enhanced" but may not be degraded. (Forget about "states' rights.")
Long before HIPAA, when I was in the armed forces, when personnel were transferred from one location to another they carried their medical records with them; they could be reviewed by the "patient" while in transit.
In all honestly, no practitioner in recent memory has refused to show me my records.
Some medical record mistakes are due to "assumptions." Assumptions ALWAYS are dangerous, and when the assumption is made on a person's health, they can be deadly assumptions.
Some, probably most, are made through carelessness, either on the part of the person creating the report or the person transcribing the report. (I know one top surgeon who writes his reports directly into the system; he uses a voice recognition system. He probably is a rarity.)
In Ontario (Canada), the College of Physicians and Surgeons of Ontario under a Medical Records heading states that:
- Patients have a right of access to their personal health information that is in the custody or under the control of a HIC, including any information that has been stamped or indicated as confidential, unless an exception applies. 28 Physicians should consult section 52 of PHIPA for a comprehensive list of such exceptions and should seek the guidance of the CMPA or their legal counsel if unsure about how to respond to a request for access.
Physicians cannot refuse to grant a patient access to their records for the purpose of avoiding a legal proceeding.
If a physician has refused a patient access to his or her record, the patient is entitled to make a complaint to the IPC under subsection 54(8) of PHIPA.
The Doctors(sic) Company, which as the name implies, is for doctors and not for patients, discusses what a doctor may do with records received by, or for, the patient.
- If a patient brings his or her past medical records to my office, am I required to maintain all of the copies?
No, however, the physician should review, extract, and photocopy any information that he or she might need from that record and then return the original documents to the patient. The retained information or documentation then becomes part of the patient’s permanent office record. Be aware that if the physician keeps all of the patient’s medical records, he or she could be held liable for information related to other specialties.
Bottom line: While the new practitioner may not maintain the patient's file from the previous practitioner, the new doctor should at least REVIEW the information - and possibly transfer over any errors to the new practitioner's files.
IN THE UNLIKELY EVENT that your doctor refuses to let you review your own medical records (or turn them over to you if you are going to a new doctor - for any reason), one retired practitioner, writing on the Democratic Underground.com suggests that the places to turn (complain) are
- Health insurer
- State medical commissioner/board
- State insurance commissioner/board
- State representative and state senator re THEIR offices contacting the state medical commissioner/state insurance commissioner. State commissions typically have a legislative liaison person on their staffs who can generally put a lot of pressure on people like this doctor.
The first paragraph of HIPAA's Your Health Information Privacy Rights PDF file reads
- …gives you rights over your health information, including the right to get a copy of your information, make sure it is correct, and know who has seen it.
- You can ask to see or get a copy of your medical record and other health information. If you want a copy, you may have to put your request in writing and pay for the cost of copying and mailing. In most cases, your copies must be given to you within 30 days.
You can ask to change any wrong information in your file or add information to your file if you think something is missing or incomplete. For example, if you and your hospital agree that your file has the wrong result for a test, the hospital must change it. Even if the hospital believes the test result is correct, you still have the right to have your disagreement noted in your file. In most cases, the file should be updated within 60 days.
Individual states may have additional requirements, but they must be in line with basic HIPAA regulations.