In most cases, errors in medical records are difficult and time-consuming to fix.
Under federal Health Insurance Portability and Accountability Act, more commonly known as HIPAA, patients have the right to request that practitioners correct errors in their medical records. However, the provider has only up to 60 days to respond and can ask for a 30-day extension, making it an especially long process. Corrections are generally not made immediately and can take quite a while to visibility show up in a patient’s file. This can be an inconvenience if a patient needs the changes sooner rather than later for a variety of reasons. Moreover, a physician also can refuse to alter a record if a reason is made in writing.
If a change is made, the clinician cannot alter the original note but, rather, must amend the note based on facts presented by the patient that can be passed along in the electronic medical record (EMR). Most EMR programs do not let the patient edit an electronic note, although this may be an added feature that is available sometime in the near future as software engineers are working on new developments.
“There’s not a smooth process for doing that in today’s EMRs,” Deven McGraw, an attorney and chief regulatory officer for Citizen, indicated. “They didn’t really build that into the certification criteria.”
To complicate matters further, any changes requested, the timing and ability of an office to do so depends on the process that is typically followed by that facility. A doctor might refer the patient to the office staff or a nurse who might then refer the patient to the practice’s health information or medical records office. Once there, the records staff could send the patient back to the doctor. Trying to make headway in larger facilities with many different departments and sometimes convoluted processes can be especially challenging. This may be the case at a hospital, or a practice affiliated with and/or operating within a hospital, for example.
It is unclear whether there are federal protections or a process for patients to ensure that physicians who accept requested changes actually do so and make them visible in the patient’s online portal.
Another reason that doctors might list a medical condition in a patient’s records incorrectly is to ensure coverage by a medical insurance company. If preexisting conditions are exempted from coverage, for example, a chart may be tweaked to reflect a condition that is. This has sometimes been the case for asthma, for example. When a patient visits a doctor’s office for asthma treatment and has a plan that considers this to be a preexisting condition, the visit may be coded as ‘bronchitis’ or a similar condition. Another example is coding bloodwork taken to monitor vitamin D levels as an osteoporosis visit in order to reduce the patient’s out-of-pocket costs.
“That’s not just wrong, it’s potentially harmful,” said Heather Gantzer, MD, past chair of the American College of Physicians’ Board of Regents. “If the patient came to the ED (emergency department) with acute back pain and compression fracture on a plane x-ray, and the ED team sees osteoporosis in the patient’s history, a treating physician might say, ‘this happens’ in people with osteoporosis, and initially discount any idea of something more serious. If the patient’s record didn’t indicate osteoporosis, maybe you are worked up with an MRI sooner rather than later, to be sure it’s not a tumor.”
The long and short of the matter is that making changes to records is not easy. Patients are their own best advocates. It is important to ask a doctor at the time of the visit if there is any questions about what is being done or written down in a chart. This will help to avoid a major headache down the road.