In 2004, I found a golf-ball sized lump under the skin on my torso. My primary care doctor sent me to a surgeon who removed the tumor.
Two weeks later I was diagnosed with a rare lymphoma. Internet research revealed it to be terminal. That led me on the chase for information that culminated in my becoming “Every Patient’s Advocate.”
During that odyssey, I requested and reviewed copies of the medical records and pathology reports about my tumor as they were generated. When I reviewed the records, one piece of information jumped out at me – a notation that pre-surgery, the tumor was “red and painful.”
But – it wasn’t. Slightly pink, maybe. But it never did hurt.
As many readers know, it turned out that my diagnosis was wrong. I never had lymphoma. I’ve never had treatment. I still wonder if that “red and painful” notation played any role in the misdiagnosis.
Mistakes in medical records can lead to many long term and difficult problems. Misdiagnosis is only one. Wrong treatment, duplicated tests, billing mistakes, even medical identity theft – mistakes in our records can become dangerous to our health and our wallets.
Unfortunately, the frequency and probability of mistakes are multiplied with our increasing reliance on technology. For decades, doctors dictated notes into a transcription machine, a transcriptionist typed up those notes, then returned them to the doctor to be filed. Those paper records might later be copied and sent elsewhere, but they mostly stayed in the doctor’s office.
Today patient medical records are created electronically and kept in digital files. Our records are regularly forwarded and shared by our doctors. Mistakes are easily replicated.
Compounding the problem is that much of today’s medical transcription is being done overseas, just like customer service or computer help desks. Not all foreign transcriptionists speak English. Many of our doctors are not native English speakers either. Further, much of the transcription is being done by computers that “listen” to the dictation. We can only imagine how many mistakes there might be.
It is important we patients review our records and correct any mistakes we find. They aren’t being reviewed by the doctor’s staff. We need to review them ourselves.
By law, we have the right to get copies of our records, examine them, and request errors be corrected. Here’s how: http://bit.ly/correctrecords
Yes, it takes time. It may be a hassle. But the peace-of-mind is worth the effort.
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