Reviewing your (child's) medical records

[ajasfolks2]

Just as a parent should/would fully review the school record for child, so should the parent review the complete medical record for child at pediatrician and allergist and any other med care providers.

So, what are the rights of parents/patient if med records have inaccuracy or an "opinion" that is not based in fact in the record?

HIPAA only goes so far as to access . . . but not much there so far as right to correct inaccuracy, yes?

Thoughts and suggestions?

[twinturbo]

A lot of our developmental ped reports had glaring clerical errors due to being outsourced to another country to be written in report form. It was done through university and we were not informed until adter the fact so 20/20 hindsight I'd start asking before any more records are made. It's a horrendous bureucratic feat to get corrections. It would be easier to add a separate statement to amend the existing file.

I also start leanin' on folks when I see things get out of line. Using the Austin Powers method I want to know who number 2 is working for and if it's not ME then I find someone competent who will. Like when I start seeing statements about my emotional state when my kid is anaphylaxing right in front of everyone that's a hell no. That required some one on one time where I said report on the patient in your care confirm we understand one another.

[LinksEtc]

A very helpful article.  Actually, I like that whole patient empowerment site.

http://patients.about.com/od/yourmedicalrecords/a/howtocorrect.htm

[CMdeux]

I had to lean pretty hard on a hospital administrator to get "parents suspect allergic reaction" amended to read "florid presentation of anaphylaxis" when DD was a baby.

Yeah.  Wasn't much "suspect" about it, actually-- and the attending physician KNEW IT when he finally showed up.  They didn't triage, and therefore didn't call for transport (which they should have done, since post-disaster, they weren't actually an operational ER and had NO PHYSICIAN ON-FLOOR).  Which would have been fine IF the way they coded it had been how it was going down-- but it wasn't.

Our child was on the edge of "conscious" when we rolled through the ER doors shrieking for help.

Similar to TT, I leaned hard on them about that coding-- with the reasoning that if they CHOSE to mis-code that, it could have a deleterious impact on our future ability to access appropriate resources for MANAGEMENT of our DD.  Oh, and that it would sure be a shame if we had to get ugly over how poorly they "handled" us that morning.  (Our pediatrician and brand new allergist had already apparently had parts of that conversation, by the way-- including things like "what do you MEAN you don't have a peds crash cart on floor?") So Ms. Administrator knew that wasn't an idle threat; they were grossly incompetent, and they (and we, obviously) were VERY lucky that she didn't die.  Because she certainly didn't get any care for the first thirty minutes we were there-- nobody even checked in on us.  DD was not awake/was unconscious at that point.  Hard to know which given that she was 11months old.  We also told them very specifically that she was anaphylaxing-- TO PEANUT.  I still have very serious PTSD when I think about that morning.  I have never felt more hopeless, helpless, and heartbroken in my life. 

I was deeply unpleasant to that hospital administrator, and I have NO regrets about that.  She was CYA-ing her staff. 

[hurt]

Thoughts and suggestions?

The first step is to make sure you get all of your records.  The office originally did not give us all the allergy records even though I wrote on the release form "any and all" allergy-related records.  I had to call back and tell them I wanted the phone conversations also.  BTW, this is a dr that I only met once ... we never had any problems with my former allergists, very nice, very professional, very competent.

[ajasfolks2]

After reading links' link:
So, after submitting the proposed amendment, the med provider has 60 days to respond.

Side bar:  also might be interesting to see what MIB has, esp if working on life insurance:
http://www.mib.com/

[LinksEtc]

They can extend another 30 days.

The provider or facility must act on your request within 60 days, but may extend up to 30 days if they provide a reason to you in writing.

If they have refused to amend your records as per your request, you may submit a formal, written disagreement which must be added to your file.

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You should tread with caution, however ...

"Doctors Reject Difficult Patients, Denying Them the Medical Care They Need"
http://patients.about.com/od/doctorsandproviders/a/dealwdifficultpts.htm

[Gray]

*** poof ***

[LinksEtc]

Tweeted by @writeo & @Farzad_MD

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"Defeating The Medical Records Paper Copy Scam"
http://www.litigationandtrial.com/2014/03/articles/attorney/medical-records-paper-copy-scam/

We are not requesting paper copies. Do not bill us for paper copies. The HITECH Act and its regulations do not allow you to bill for paper copies when an electronic copy has been requested.

If any of the above records are available only as paper copies, and have never been made into an electronic format, please identify the record and provide the cost of copying.

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FWIW, all of the docs & hospitals we have dealt with have been very decent in terms of charging for copies of records.  In fact, I don't remember having to pay any of them, even for very large files.

[LinksEtc]

"The Smart Way to Create a Transparent Workplace"
http://www.wsj.com/articles/the-smart-way-to-create-a-transparent-workplace-1424664611?mod=e2tw

the same openness that at times can increase accountability, collaboration, knowledge sharing, innovation and productivity can also undermine it

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Tweeted by @SusannahFox


"OpenNotes: Putting Medical Record Transparency to the Test"
http://www.rwjf.org/en/research-publications/find-rwjf-research/2014/02/opennotes--putting-medical-record-transparency-to-the-test.html?cid=xsh_rwjf_tw

She cautions, however, that because OpenNotes appears to be popular and effective in primary care settings does not necessarily mean that it will be equally so in specialty settings—especially those such as psychiatry and oncology, where the balance between openness and patient protection may have to be set differently.

[LinksEtc]

Tweeted by @CancerDotNet

"Keeping a Personal Medical Record"
http://www.cancer.net/navigating-cancer-care/managing-your-care/keeping-personal-medical-record?et_cid=34067702&et_rid=539063352&linkid=http://www.cancer.net/navigating-cancer-care/managing-your-care/keeping-personal-medical-record

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Tweeted by @subatomicdoc

"Electronic medical records, for-profit medicine, and the doctor-patient relationship"
http://www.thehealthculture.com/2014/12/electronic-medical-records-for-profit-medicine-and-the-doctor-patient-relationship/?utm_content=buffer0d9d4&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

A Canadian physician friend, though, says he uses an electronic record that does not disturb his rapport with patients.

we tend to include extraneous information to justify higher levels and satisfy potential insurance company audits. Canada has only two levels, so doctors’ notes are short and succinct.

[LinksEtc]

What exactly is the law on requesting medical records?

[LinksEtc]

Tweeted by @drval

Lawyer group auditing EMRs state that the info contained is too unreliable to be admitted as evidence in court: avemarialaw.edu/lr/Content/art…

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"ELECTRONIC HEALTH RECORDS SYSTEMS: TESTING THE LIMITS OF DIGITAL RECORDS’ RELIABILITY AND TRUST"
Barbara Drury,† Reed Gelzer,†† and Patricia Trites†††

http://www.avemarialaw.edu/lr/Content/articles/v12i2.Gelzer.pdf

[LinksEtc]

These are more of a doc issues, but interesting.


Tweeted by @EricTopol

"Doctors Find Barriers to Sharing Digital Medical Records"
http://www.nytimes.com/2014/10/01/business/digital-medical-records-become-common-but-sharing-remains-challenging.html?ref=health&_r=0

Regardless of who is at fault, doctors and hospital executives across the country say they are distressed that the expensive electronic health record systems they installed in the hopes of reducing costs and improving the coordination of patient care — a major goal of the Affordable Care Act — simply do not share information with competing systems.

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"Feds move into digital medicine, face doctor backlash"
http://www.usatoday.com/story/news/nation/2015/02/01/backlash-against-electronic-medical-records/21693669/

A group of 37 medical societies led by the American Medical Association sent a letter to Health and Human Services last month saying the certification program is headed in the wrong direction, and that today's electronic records systems are cumbersome, decrease efficiency and, most importantly, can present safety problems for patients.

[LinksEtc]

Tweeted by @ahier

"End-of-life instructions find no place in electronic health records"
http://www.politico.com/story/2015/01/end-of-life-instructions-ehr-114139.html

Recording the desires of patients who are on their death beds — or even noting whether a patient has appointed someone to make medical decisions on his or her behalf — has become a huge gap in the nationwide effort to computerize patient care. The few hospitals trying to come up with their own digital approaches are finding it’s not easy.

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Tweeted by @CMichaelGibson

"Medical Records: Top Secret"
http://www.nytimes.com/2014/11/09/sunday-review/medical-records-top-secret.html?ref=opinion&_r=1

“When hospitals talk about Hipaa or charge for releasing records what they’re really saying is, ‘I don’t want to do this and I have to find an excuse,’ ” said Dr. David Blumenthal, president of the Commonwealth Fund, who was previously President Obama’s national health information technology coordinator.