lady-at-table-frustratedThis story is told by an intern and then a doctor who spent over 35 years around medical records with a never ceasing amazement of 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 record keeping and documentation.

Medical Errors Aplenty

Regretfully, such mistakes (the term “mistakes” because people should 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 as an organ removal, amputation or family history data] these mistakes should be promptly addressed and corrected in a person’s medical records.

According to many news articles, 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 people — notably applicants for a life insurance policy — should not rest until they have rectified such inaccuracies.

When the doctor recently visited a local hospital’s emergency room for a deep cut in his leg, he requested his medical records to see what had been recorded. Here is what was discovered:

  1. He was given an injection of lidocaine.
  2. He was given a complete level 3 physical exam.
  3. He was bandaged and the bleeding was controlled.

The problem: None of this was accurate. He had bandaged and controlled the bleeding before he drove to the emergency room; if he hadn’t he would have bled to death (he cut an artery in his leg). Additionally, no medical person touched him in the emergency room, so how could it have been recorded that he was given and completed a level 3 exam or an injection of lidocaine?

He ended up leaving the emergency room after several hours of waiting. But to submit a bill, hospital staff had to document in the medical record that they had followed through with something. However, when he challenged the medical record, staff made corrections and reduced his bill accordingly.

This should be warning to people 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 people should never believe that all their medical records are accurate until the documents have been reviewed. Then do not rest until the records are accurate.

Three Very Good Reasons for Checking

Verifying the accuracy of medical records can:

  1. Save people’s lives;
  2. Save them money; and (not least)
  3. Keep them from being denied life insurance coverage.

Yes, medical record mistakes can be life-threatening, but even if not, such errors are (more often than not) detrimental to people’s pocket books and their ability to get the life insurance coverage they deserve and need.

According to the story, the doctor’s medical records, once corrected, saved him nearly $1,000. Many people have saved money on life insurance premiums by getting their medical records corrected. And some have gone from a denial of life insurance coverage to full coverage.

People’s medical records are a third party witness for them or against them — especially if there are legal questions about their healthcare. And so it is imperative they know what has been documented in their records.

And, by the way, do not think that the Health Information Portability and Accountability Act (HIPAA) does anything to prevent such mistakes from happening or always protect people.  HIPAA provides insurance carriers and government facilities with the ability to collect information they need to advance the Patient Protection and Affordability Care Act (ACA).

Of course, we all know now how effective the Patient Protection and Affordability Care Act is, with nearly 50 percent of co-ops failing and even more of them subject to failure.

It is not unusual for a person applying for life insurance to find out for the first time about what is contained in their medical records. They should not apply for life insurance coverage only to make sure their medical records are 100 percent correct. They should simply ask for copies of their records whenever they visit their healthcare provider.

If they do not recognize or understand what is documented in their medical records, then should persist in getting clarification until they are comfortable with the information, because the documentation is about them. It’s their life, their money and their health. If they don’t do this, nobody will — and that could be devastating.