To Your Health
November, 2016 (Vol. 10, Issue 11)
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Proactive Patient: Know What's in Your Medical Record

By Tomas McFie, DC, PhD

Having spent over 35 years in and around health care records, first as an intern, then as a doctor and now as a life agent, it never ceases to amaze me how frequently someone is shocked about the data found in their medical record.

Be it a prescription never filled, a physician's comment never broached with the patient, a procedure recommended but never discussed, a diagnosis made without patient acknowledgment or an error made in the transcription process, millions of Americans are detrimentally affected each year because of inaccurate medical record keeping and documentation.

Regretfully, such mistakes, and I use the term mistakes because I would never accuse anyone of tenaciously endangering their patient's life, do cause catastrophic events in the lives of millions. Be it merely a minor mistake such as height, weight, date of visit, or a significant major mistake such as an organ removal, amputation or even family history data, such mistakes should be promptly addressed and corrected in your medical record.

According to CBS News, 12 million Americans are misdiagnosed every year. This is based on a recent study in the British Medical Journal on quality and safety. This means one out every 20 patients is misdiagnosed! How much of this misdiagnosis is based on errant information in the medical record is currently unknown, but it is significant enough that you should never rest until you have rectified any mistakes that are currently in your medical record.

Recently when I visited the local ER facility for a deep cut in my leg, I requested my medical records to see what had been recorded. Here is what I discovered:

  • I was given an injection of lidocaine.
  • I was given a complete level 3 physical exam.
  • I was bandaged and the bleeding was controlled.

The problem was that none of this was accurate. I had bandaged and controlled the bleeding before I ever drove to the ER or I would have bled to death (I cut an artery in my leg). Besides, no one ever touched me in the ER, so how could I have been given and completed a level 3 exam or an injection of lidocaine? I ended up leaving the ER after several hours of waiting, but to submit a bill, they had to document in the medical record that they had done something. When I challenged the medical record, the corrections were made and my bill was reduced accordingly.

This should be warning to you and others that things get documented in the medical record without your knowledge or consent more frequently than you would like to contemplate, especially if there is a third-party payor involved. Yes, we all want to trust our medical doctor and we all love our care providers, but they are human and humans make mistakes. So never believe your medical record is accurate until you review it yourself. Then don't rest until it is accurate. Here are some reasons why:

  • It could save your life.
  • It could save you money.
  • It could keep you from being denied life insurance coverage.

Yes, medical record mistakes can be life-threatening, but even if they are not life-threatening, more often than not they are detrimental to your pocketbook and your ability to get the life insurance coverage you deserve and need. My medical record, once corrected, saved me nearly $1,000. You may save money on premiums by getting your medical records corrected. You may even go from a denial from the life insurance company to full coverage.

You see, your medical record is a third-party witness either for you or against you; especially if there is ever any legal question about your health care. Thus, it is imperative that you know what has been documented in that record because it could be that it isn't in your best interest for it to be documented the way it is.

And by the way, don't think for a minute that the Health Information Portability and Accountability Act (HIPAA) does anything to prevent such mistakes from happening, or protect you if they do. All HIPAA did was provide insurance carriers and government facilities the ability to collect the information they needed to advance the Patient Protection and Affordability Care Act (ACA). Of course, we all know now how effective ACA is right now, with nearly 50 percent of the co-ops failing and even more of them subject to failure.

It is not unusual for a person applying for life insurance to find out for the first time about what is contained in their medical record. But it's not recommended, nor should it be, that you should apply for insurance coverage to make sure your medical record is 100 percent correct. Simply ask for copies of your medical record each time you visit your medical provider. If you don't recognize or understand what is documented in your medical record, then ask and persist until you are comfortable with it, because this is about you. It's your life, your money and your health. If you don't do it, no one will, and that could be devastating.

Tomas McFie, DC, PhD, is the founder of Life Benefits and author of multiple books including Retirement Curveball.