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In 2004, I
found a golf-ball sized lump under the
skin on my torso. My primary care doctor
sent me to a surgeon who removed the
tumor.
Two weeks later I was diagnosed with a
rare lymphoma. Internet research
revealed it to be terminal. That led me
on the chase for information that
culminated in my becoming “Every
Patient’s Advocate.”
During that odyssey, I requested and
reviewed copies of the medical records
and pathology reports about my tumor as
they were generated. When I reviewed the
records, one piece of information jumped
out at me – a notation that pre-surgery,
the tumor was “red and painful.”
But – it wasn’t. Slightly pink, maybe.
But it never did hurt.
As many readers know, it turned out that
my diagnosis was wrong. I never had
lymphoma. I’ve never had treatment. I
still wonder if that “red and painful”
notation played any role in the
misdiagnosis.
Mistakes in medical records can lead to
many long term and difficult problems.
Misdiagnosis is only one. Wrong
treatment, duplicated tests, billing
mistakes, even medical identity theft –
mistakes in our records can become
dangerous to our health and our wallets.
Unfortunately, the frequency and
probability of mistakes are multiplied
with our increasing reliance on
technology. For decades, doctors
dictated notes into a transcription
machine, a transcriptionist typed up
those notes, then returned them to the
doctor to be filed. Those paper records
might later be copied and sent
elsewhere, but they mostly stayed in the
doctor’s office.
Today patient medical records are
created electronically and kept in
digital files. Our records are regularly
forwarded and shared by our doctors.
Mistakes are easily replicated.
Compounding the problem is that much of
today’s medical transcription is being
done overseas, just like customer
service or computer help desks. Not all
foreign transcriptionists speak English.
Many of our doctors are not native
English speakers either. Further, much
of the transcription is being done by
computers that “listen” to the
dictation. We can only imagine how many
mistakes there might be.
It is important we patients review our
records and correct any mistakes we
find. They aren’t being reviewed by the
doctor’s staff. We need to review them
ourselves.
By law, we have the right to get copies
of our records, examine them, and
request errors be corrected.
Yes, it takes time. It may be a hassle.
But the peace-of-mind is worth the
effort.
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