Having spent over 35 years in and around health care records, first as an intern, then as a doctor and now as a life insurance agent, it never ceases to amaze me how frequently people are shocked about the data found in their medical records.
Be it a prescription never filled, a physician’s comment never broached with the patient, a procedure recommended but never discussed, a diagnosis made without patient acknowledgement, or an error made in the transcription process, millions of Americans are detrimentally affected each year because of inaccurate medical recordkeeping and documentation.
Medical errors aplenty
Regretfully, such mistakes (and I use the term “mistakes” because I would never accuse anyone of endangering a patient’s life) do cause catastrophic events in the lives of millions. Be it a minor mistake (such as inaccurate data about one’s height, weight or date of visit) or a major mistake such (e.g., organ removal, amputation or family history data) such mistakes should be promptly addressed and corrected in clients’ medical records.
According to CBS News, “12 Million Americans” (or 1 in every 20 patients) are misdiagnosed every year. How much of this misdiagnosis is based on errant information in medical records is unknown. But the rate is significant enough that your clients — notably applicants for a life insurance policy — should not rest until they have rectified such inaccuracies.
When I recently visited a local hospital’s emergency room for a deep cut in my leg, I requested my medical records to see what had been recorded. Here is what I discovered:
I was given an injection of lidocaine.
I was given a complete level 3 physical exam.
I was bandaged and the bleeding was controlled.
The problem: None of this was accurate. I had bandaged and controlled the bleeding before I drove to the ER; if I hadn’t I would have bled to death (I cut an artery in my leg). Besides, nobody touched me in the ER, so how could I have been given and completed a level 3 exam or an injection of lidocaine?
I ended up leaving the ER after several hours of waiting. But to submit a bill, hospital staff had to document in the medical record that they had done something. When I challenged the record, staff made corrections and reduced my bill accordingly.
This should be warning to clients that things get documented in their medical records without their knowledge or consent (especially if there is a third party payor involved) more frequently than they would like to contemplate. Yes, we all want to trust our doctors and healthcare providers, but they are human. And humans make mistakes.
So you should never believe that clients’ medical records are accurate until the documents have been reviewed. Then don’t rest until the records ARE accurate.