medical records errors and omissions

The Dangers of Errors & Omissions in Your Medical Records

So you get a copy of your medical records & dive in, reading line by line, trying to make sense of your new lung cancer diagnosis.

“Wait a second, this doesn’t sound right. This is a mistake. I don’t have a history of a heart condition & I don’t smoke cigarettes”, you mutter to yourself.

You call your oncologist’s office to report the mistake you found & ask to have it updated. You’re told to write down the correction & fax it to the office. You do exactly as you are told.

A month later at your next follow up appointment, you ask your doctor if your record was updated & the correction was made. He looks up at you with a deer-in-headlights-look that clearly signifies a NO.

On your way out, you stop at the front desk, write the correction down again, & the staff assures you they’ll take care of it.

Lather, rinse, repeat. Months later, it’s still not corrected. You also find out your cancer is progressing. The nurse asks if you are still smoking cigarettes. Your treatment options are discussed but there are concerns of trying new medications because of your heart condition. Cardiotoxicity is a common side effect of many cancer treatments. It may exclude you from a clinical trial.

There are endless stories of errors & omissions that patients have found upon reviewing their medical records.

Some common mistakes that are noted include:

  • Incorrect diagnoses & conditions

  • Incomplete family histories, such as an extensive family history of cancer

  • Medications that you’ve never taken or have discontinued

  • Reports of pregnancies in those who have never been pregnant

  • Surgeries in people who have never been operated on

  • Symptoms that have never been experienced

  • Documentation of mental health illnesses, from depression, bipolar disorder, to suicidal ideation where no history exists

  • Errors in tobacco, alcohol, substance use

Imagine getting a copy of your records and finding someone else’s records in your file, such as a sexually transmitted disease (STD) screening or an imaging or surgical report.

Imagine having an anaphylactic allergy to morphine and no matter how many times you make a note of it in your paperwork, it never makes it into your file. Some omissions can be deadly.

Patients need to be able to correct these errors & omissions.

In 2020, this is the epitome of poor workflow, information blocking, patient harm, and downright dangerous.

Unblock Health can ease the burden patients and their families face in correcting errors and omissions in their medical records. Instead of wasting precious time and effort generating handwritten requests for record amendment requests, the patient or their advocate could have logged into Unblock Health to initiate an addendum request and performed the following, entering:

  • basic patient information, name, date of birth, address, and a medical record number if available

  • the nature of the addendum request: for example, incorrect diagnosis or missing anaphylactic allergy

  • the facility contact information that needs to receive the request

  • the fax number, email address of the medical records office.

  • where the addendum request, if approved & even if denied, needs to be linked and sent: facility name, doctor name, their fax number, or mailing address.

  • contact information in case any questions arise,

  • a phone number and email for tracking and communication updates from the hospital.

The Unblock Health addendum request is received by the healthcare provider’s office and a communication confirming receipt is sent to the patient. The healthcare provider may electronically inquire about the addendum request if there are any questions or concerns, all of which are documented and tracked within the Unblock Health platform. Unblock Health requests are triaged by urgency specified by requester. Urgent requests are flagged for expediting. Patients receive real-time tracking updates to monitor requests. Unblock Health requests are carefully tracked. If no response is received acknowledging receipt of the Unblock Health addendum request within a business day for an urgent request, a reminder will be initiated. Patients will receive notifications of approval or denial via Unblock Health. Unblock Health provides patients with a standardized solution to also address addendums that are denied, tracking the entirety of information exchange and communication. Patients may desire to have their denied addendum requests added to their medical record and may request to do so via the Unblock Health platform.

Requests that are ignored will be publicly addressed on a wall of shame and by tagging the facility on Twitter, tagging ONC, OCR, & HHS for awareness. Formal complaints will be filed as necessary. Similarly, requests that are addressed and completed will be acknowledged in the public domain on the wall of data access champions, tagging ONC, OCR, & HHS for awareness.

Have you ever found an error or an omission in your patient record? If you have, were you able to successfully get it corrected?

Yours in Unblocking Health,

Shahid Shah & Grace Cordovano

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