Medical Record Errors

Because I am an engaged patient, I find errors in my medical records fairly often. Usually, they are minor issues and I wonder if it is worth raising it to the doctor because it probably won’t make a difference in the long run. For example, I have seen that they marked me as male in a note or it mentioned my pain was in my lower back instead of my upper back.

Other issues, however, are more significant. Several years ago, a doctor accidentally marked Diabetes on an MRI order form, and somehow that added the problem to my health condition list. When that specialist sent the notes to my primary doctor and my rheumatologist, then they added Diabetes to my health conditions and suddenly people were asking me what my glucose levels were. They seemed very concerned when I told them I had no idea!

My most recent example was both shocking, and the response I received was a troubling reminder of how the healthcare system sees patient input. First, for those who don’t know me, I am 19 years old and in college. I have never been pregnant, and I have no children.

So, you can imagine my surprise when I saw this in my medical record…

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You can imagine that I was not pleased to see that, especially since it had already been sent to two other doctors. Who knew that I had a child at 13? Apparently that imaginary child didn’t survive though, but somehow imaginary pregnancy 2 was able to survive.

I understand that mistakes happen, and it is very easy for the doctor to accidentally mix up two patients or accidentally click the wrong options in their very, very click-intensive EMR. However, I was not pleased with the response when I had my health assistant at CareSync try to get the record corrected for me.

The office staff said that “the patient must have told us that if it is in the record.”

They also would not take my health assistant’s correction, despite the fact that the history was only incorrect in one visit and in the month prior it said I had zero pregnancies and zero children.

In order for me to get it corrected, I had to submit the request in writing. They then also called me to confirm. 14 days later, I received a corrected copy in the mail – despite me asking in the written form if they could email it to me (and acknowledged that it is not secure).

How do we reduce the chance for errors in EMR systems? Simple documentation errors can cause major medical errors when someone else reviews the documentation as a source of truth (often believing that over what the patient says because “it must have been so because it was documented in the EMR)

How do we make it easier to get errors corrected? I wonder how many patients even know that they can get errors corrected.

Have you had experiences with errors? I would love to hear your stories.