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Medical Reports Are Not Sacred Scripts



All of us, at one time or another, must rely on medical professionals' care for some physical or mental difficulty and we expect those individuals to be accurate in their reporting. Medical reports, after all, are the "bible" upon which a long line of medical providers will rely when assessing what to do for you in the future. Therefore, that information must be accurate and here's where many of us fall down on the job; we don't review them for accuracy.When we don't do our homework here, mistakes take on a life of their own and you can "become" a smoker, a drug abuser, someone who is a social pariah and the list goes on. Yes, some of the mistakes are in the software coding and some is in the data input, but who's checking all of that on their end? Go figure.

Totally relying on anyone for a report is like stepping into a room with no lights on and hoping you won't fall flat on your face. Well, that dark room is that report you have been given or failed to request for your files. What, you don't ask for a copy of the report after you've received services? Really? You rely, blindly, on it being accurate in all respects? Yeah, and I always think all the cars will stop when I put a foot into the crosswalk because that's the law and everyone follows it.

One small example, in my own case, may be illustrative of what can happen. First, remember that not all medical reports are written here even though they may be dictated here in the US. Much of medicine in terms of reports and billing has been offshored and not everyone is conversant in our form of English.

My name should tell anyone that I'm a female, but if your language doesn't have my name in it, what might happen? Well, in my case, I was listed as a male. This was mistake #1. Then, the physician, who played with her hair while writing into her computer, ordered a medication that was priced at $5K because she wrote in the wrong medication. Mine should have been less than $15. In addition to these two mistakes, she made two more in medication-related issues. So, wrong gender and wrong medications.

A friend, who got a copy of her report, found that the physician she saw indicated he had done a host of tests, which he didn't. He also said that she had highly problematic medical disorders, which she doesn't.

The odd thing here is that she'd given him a detailed listing of all her diagnoses, medications and allergies so that could be put into the report. He didn't do it. Now she has to clear up the mess he has made of her medical record in just that one office. Of course, it goes into a patient portal at a hospital where his boss is an attending. He doesn't have admitting privileges because he isn't board-certified. Will he ever be?

And the hospital medical records guy? He told her they're switching to another system and things will be changed. The conversation was one of apologies, but little hope that the software will, indeed, fix things. As a gesture of atonement for their remiss records, he has agreed to provide her with, free of charge, a copy of her medical record; 1K pages long.

How could it possibly be that big? No one knows. It probably contains the medical record of an elderly woman with a similar name, but who has dire medical problems. My friend once received the woman's entire medical record in error and that's why she knows this may have happened again.

Looking through her report from another physician, she saw that, across the bottom under a fine line, they had listed all kinds of medical problems, none of which she has. When she asked about that she was told, "Oh, that's the hospital. Don't pay any attention to it. It means nothing." Means nothing and it's in a medical record? How is that? She was told they couldn't change it at any rate because they don't have access. Well, who does have access and shouldn't they be alerted? No, the office manager didn't think so.

Next time you go for a medical procedure or a hospital stay or an ER visit, be sure they make YOUR medical records available to you. There may be some surprises there.

#medicalrecords #medicalerrors #medicalsoftware #recordkeeping #medicalreview

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DR. PATRICIA A. FARRELL