Reviewing Your Medical Record for Accuracy

Cropped shot of a doctor a giving his patient advice during a consultEducated healthcare consumers acquire the knowledge necessary to be effective advocates for themselves. Below are a few quick tips and tricks to reviewing your medical record.

I always recommend a patient make his or her own written notes of what happened at an office visit during, or just after, the appointment. Things to record might include:

  • What you told the doctor either spontaneously or in response to a question.
  • What the doctor examined with his hands or stethoscope.
  • What the doctor said.

A patient has the right to request to read the notes from each office visit. If your provider has a patient portal, some of these systems allow patients to review these notes. But what if you don’t understand “healthcare speak” or the medical notes enough to know if they are accurate? You can then put on your detective hat and use clues from one record to another to help guide your efforts.

One trick is to compare the doctor’s notes with your personal notes; if the doc’s notes are the same from one visit to the next, they may be cloned and therefore, not an accurate reflection of what transpired at a particular visit. If the doctor’s notes look more complicated than what you wrote, they are probably not accurate and it would be worth questioning the provider for clarification as well.

Being your own advocate in the healthcare process is key to protecting yourself from billing errors and, most importantly, mistakes in your care. Be sure to talk to your legislator about the importance of patient review as part of the healthcare process to increase accuracy and decrease fraudulent healthcare charges.