If your hospital experience resembles most, you have a very limited and probably somewhat confused understanding of your hospital stay based on some comments from doctors and nurses. This represents a tiny fraction of the real record of your hospital stay.
For your own safety, you should obtain a copy of the official file. This will contain laboratory results, reports on any imaging studies (X-Rays, CT scans, MRI’s, etc.), doctor comments, usually called “Chart Notes,” more detailed reports from your doctors, nurses comments about you, often referred to as “Shift Notes,” and any other information accumulated during your stay. Besides these hospital notes, get the the same kind of information on a periodic basis from any health care provider. Keeping your own file of this information makes it readily available to you in an emergency.
Besides learning in detail how you were treated, you can then correct errors in your medical history. Based on considerable experience, both trivial and serious errors probably appear in your record. These could come from transcription errors. Typically, doctors dictate their reports of each encounter to a digital recorder, and a medical transcription later transfers this information to written or electronic format. In an electronic system, the doctor may type in or dictate them information directly. If the doctors do not take time to proofread the end result, perhaps because they are too busy, your history may be flawed. Based on personal experience, errors occur in most records, ranging from trivial to potentially harmful.
Another significant cause of error comes from doctors simply not listening carefully enough during an interview, particularly in emergencies. Whatever the reason, inaccurate information could come back to haunt you. For one example, in an office visit a patient with significant “white coat” hypertension, that is, blood pressure that rises sharply in a doctor’s office, had a doctor check his blood pressure. It was 190 over 96. The patient said, “It is much lower at home.” Later, when the patient obtained a copy of the doctor’s note, he found that according to the doctor, his blood pressure was “much higher” than this at home. It is easy to see how in a later emergency, someone reading this could be misled. In addition, should this misinformation make it into the patient’s medical insurance file, it might affect his coverage options. The HIPAA act gives the patient the right to correct errors in the medical record as well.
Fortunately, the passage of the Health Insurance Portability and Accountability
Act in 1996 granted patients the right to see and obtain copies of their medical files as well as control, in a number of areas, who can see this information. The law provides strict rules about the process of records release including a timetable. In most cases the information must be provided within 30 days unless you are given a reason, in which case the period may be extended for another 30 days. The only reason for refusing to surrender the records at all is when the doctor feels the information might endanger you or others. In this case, the medical provider must give you the name of a third party arbitrator. For more information, see the Health Information Privacy
information sheeet on the Health and Human Services Web site.
To get their records, patients complete a form authorizing release. Although standard forms are available on the Web, most medical institutions, clinics, hospitals or private practice situations have their own versions. Request a copy of the form from the office or medical records department in a hospital.You can see a typical release form
here. This is provided as an example only. Use an approved form from your provider.
In the section specifying the specific information requested, describe this as broadly as possible or else the medical agency has the right to decline release of part of the information. For example, you might say, “All information covering the dates of treatment including laboratory studies, chart notes, nurses shift notes, specialists reports, imaging studies, and all other information contained in my medical file.” You may have to pay a fee but it is limited to the cost of copying and supplies.
The informed patient will have a better chance of staying healthy and playing an important role in their own health care. Understanding what has been said about you and accurately knowing what happened to you in a hospital or under some other type of medical care is vital to this purpose.