Medical records sometimes afflicted with errors

Advances in medical science and technology has not eliminated errors. There is a large volume of medical records containing mistakes that can cause medical malpractice. Almost one in ten people who have online access to their medical records requested corrections, according to Office of National Coordinator for Heath Information Technology estimates. In the worst cases, an incorrect diagnosis or laboratory or scan result in a record can cause inappropriate evaluation or treatment or the administration of unwarranted and potentially dangerous drugs.

Omissions from records have serious consequences. Failure to document allergies, unrecorded laboratory results, unlisted medications or unrecorded family can lead to misdiagnosis or allow a condition to worsen. For example, failure to document laboratory findings of cancer can allow it to metastasize.

Simple mistakes can also serious problems. Errors involving a patient's name, phone number or personal contacts can hamper the ability to contact someone in an emergency or cause a bill to be sent to the wrong address. Services that were not received but placed in records can cause unjustified bills. The Health Insurance and Portability Act provides some remedies. HIPAA allows patients to ask for corrections. Patients should ask their physician or hospital for a paper or electronic form to provide corrections.

A simple error, such as an incorrect phone number, can be corrected by placing a thin line through the material and writing a proposed change in the margin or making an electronic note. Complicated errors such as an incorrect symptom or contested diagnosis may require a brief description of the error and how it should be altered.

Doctors and hospitals must respond in writing within 60 days but may have a 30-day extension. However, they are not required to accept revision requests. Patients may add another statement disputing this decision to their records. They can also file a complaint with the Ohio medical board or with the Department of Health and Human Services.

Health care facilities or doctors may reject unwarranted requests such as the elimination of potentially -excessive opioid use. Other unjustified change is a modification or elimination of a diagnosis that is requested to assure insurance coverage. Evidence needs to be reviewed to determine whether there was a doctor error or hospital evidence. An attorney can help gather and obtain expert review of this information to determine whether a lawsuit may be filed.

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