DEAR DR. GOTT: Does a patient have the right to question his or her medical records without retribution? I questioned my records after finding errors in them with the doctor’s head nurse. She corrected some of them but said she would have the office manager contact me in regards to other errors. The office manager refused to call to discuss my concerns.
For example, I got turned down twice for long-term-care insurance because my records were not up-to-date and accurate. As a matter of fact, the head nurse told me that my records had not been updated in three or four years. My records indicated at one time I had congestive heart failure, which I never did. They coded my wife’s blood work with my identity. These are only a few examples that I discovered. I am sure there were more that I was unaware of.
I sent several emails and made a phone call to the doctor’s office to follow up with me to talk about correcting my records. No correspondence back, so I requested the doctor call me and even set up a one-on-one appointment to resolve the issues at hand. WOW! What did I do that was wrong? Was I not supposed to question my records and have then updated and accurate? Apparently not. I did finally receive an email from the office manager, stating, “It appears from your concerns and multiple emails that the patient/provider relationship has been damaged and that an issue of distrust has now been established, and that this notice will serve as termination of our patient/doctor relationship for both you and your wife.” They will provide emergency medical care and prescription refills for 30 days. We need to find a new physician, and they will forward our records to them.
I was content with the service the doctor provided my wife and me. I was not questioning his ability and knowledge, nor did I distrust him as a doctor. I was concerned that my medical records were not accurate and were outdated. I was not happy with his staff that my records were inaccurate.
What is your expert opinion and advice on all of this?
DEAR READER: To begin with, I am appalled. How on earth can records be outdated by three or four years? Was everything recorded on a machine and the staff simply hasn’t had sufficient time to transcribe the information? Did your doctor write notes every time you had an office visit, or was some other method of documentation instituted? From where did the congestive heart failure originate? Were your records mixed up with someone else’s who might share your name? Really, where can you honestly put the blame? Do you think you are the only person in his practice who has this problem, or are other charts lacking current information and full of errors as well? My guess is that you have opened a can of worms that truly requires immediate follow-up.
If your doctor is relying on his staff to record vital information, someone has fallen down on the job, and it’s critical he be advised; after all, the ultimate responsibility falls on him. Perhaps he is completely unaware of the situation and just gave his staff a big pay raise when a more appropriate course of action might have been to investigate and, if justified, fire the person responsible. Medical records are serious business.
The only way to be prepared for an incoming patient is to review the record to determine why he or she was last in, what the situation was, what medications were prescribed and the reason for the present appointment. If a seemingly young man is reported as having a bad ticker without justification, steps must be taken to correct all misinformation. What if a cardiac medication was prescribed to you and you didn’t take the time to question it? Talk about scary! Perhaps somebody simply wrote notes in your chart that should have been included in someone else’s notes. Errors occur and accidents happen, but plain stupidity is unacceptable!
For your own well-being, I would find a new physician immediately and have him or her (with your signature for documentation) request your records. Then write to the physician via certified mail, return receipt requesting his signature, that you found it necessary to leave a practice you enjoyed because of his inept staff. Then inform your state medical board in writing of the situation. Keep it civil, but outline everything. Hopefully an investigation will follow. Good luck.