Monday, August 27, 2007

Have you read YOUR medical record lately?

Good Afternoon!

This blogging stuff is new to me.. I think I might like it though.. :) I just have to get in the mindset to talk a lot! Which really isn't a problem for me as my future readers will find out.

Have you ever wondered what is in YOUR medical record? I am a medical transcriptionist by trade, and since I have been in this profession I decided that I wanted to see my own medical records.. What did I do that for?

I was appalled by how many errors were in those permanent records. You know, records that you cannot legally alter? If a mistake is entered into your personal medical record, you cannot have it removed. Did you know that? If a nurse or resident puts in your medical record that you are antisocial or possibly paranoid, etc.. and then they do not mention why you felt the need to act in such a way.. you are permanently thought of that way. Their motto is that past behavior is indicative of future behavior..

You can add an addendum to correct the misinformation.. but if the next doctor, nurse, or other medical personnel that reads your record happens to read the wrong information and does not pay attention to any of the corrected information, (Sadly, most of the people do not read the information that they need to read to learn your situation) your very life could be in jeopardy.

Medications that you may have taken that did not agree with you could be given to you and cause you to have an allergic reaction. If you take 60 micrograms of a medication, and the doctor mistakenly writes 600 milligrams of this medication, did you know that your health could be in danger?

I work very hard to be sure that what I transcribe is correct, yet I have absolutely no control over what the doctor says. I cannot alter what he/she dictates.

So, I am using today's blog to hopefully get the word out to everyone who is a patient now, or who has been one in the past, to check your own medical records! Make sure that what actually should be in there is there, and that the misinformation is corrected.

Your life or the lives of your family could very well depend on that. I know it is a pain to get your records, and for some it is quite costly. Yet, this is something that needs to go on your own "To Do List" Yesterday.

I asked one of my own doctors just last month if he ever actually reads the written records that he dictates, because there were so many mistakes in just ONE of his clinic visits for me that I had to wonder if he just automatically signed the paper and did not actually read it to make sure it was done right.

He is a great doctor, and he actually went through it with me, marking the errors in medications, diagnoses, and general spelling errors in it, and then he had it corrected for me and sent me the newly corrected copy.. Most doctors do not do that..

You have to be your own champion.. your children's champion, your spouse's champion, and lastly your parent's/siblings/and other family's champion. No one else will do it for you.. Don't even get me started on the HIPAA laws, either..

Thanks for reading today!

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