Posted by Bill Sandweg on 12 April 2021.
You have a right to see your medical records. Recent changes in the law and in federal regulations are increasing your rights in this area. Know your rights and take advantage of them.
If you have received medical treatment in the past couple of years, you have probably been invited to register to use a patient portal by your provider. These portals have many uses. You can schedule appointments, exchange messages with your provider and review your records. These are all important and helpful actions and you should be sure to register and take advantage of them.
Perhaps the most revolutionary of these actions is the opportunity to see your medical records almost as soon as they are created. You get to see what the doctor or other provider has written about you and about your visit. New regulations, which just took effect earlier this month, prohibit most blocking of access to a patient’s records and require that you be provided electronic access to eight types of medical records. These categories include histories and physicals, which are important in setting the stage for your treatment and identifying your chief complaint, consultant notes, procedure notes, imaging reports, laboratory reports, pathology reports and office notes of the provider.
As I have written before and as anyone who has looked at their medical records can attest, medical records often contain inaccuracies. Somebody gets something wrong. It may be a part of the history of your illness that you correctly described to the provider but the provider misunderstood or misheard. It may be a diagnosis that someone erroneously made. It may an incorrectly recorded test result. In what can be a devastating error, the record may actually refer to a completely different person, who may have the same or a similar name. Whatever it may be, once it is in your records, it tends to stay there and to be repeated over and over until it takes on the character of undeniable truth.
The almost real time access to your records provided by the new regulations gives you the opportunity to nip these errors in the bud, or to at least correct them before they can cause you actual harm. You can ask that the errors be removed and the record corrected. The provider, as a matter of law, has 60 days in which to respond to your request. If the provider denies your request, they must notify you in writing and keep your request and their denial as part of your medical records. It is important, therefore, that you put some thought into your request and make it clear and complete. Be sure to carefully describe the record you contend is in error and what is needed by way of correction.
The world around us is changing fast. Sometimes those changes are to our detriment. Sometimes, as with the requirement for electronic access to your medical records, the change is a good one. Take advantage of this change to review your records before some mistake you didn’t even know was there bites you on the rear end.