Make sure your medical records are accurate

A solid, dependable patient-doctor relationship sure makes good health easier. Study after study shows that when patients trust and are comfortable with their doctors, it has measurable health benefits. Not only are you inclined to share more information with your docs, it also makes a difference in how you respond to treatment, improving your compliance with prescribed therapies and boosting your healing and recovery.

That’s why it is so important that your medical records — especially now that they are electronic and shared among many docs — are accurate. You expect them to contain all your basic vital info (height, weight, age, blood pressure, various cholesterol levels, glucose, some hormone and inflammation markers, and perhaps levels of some key nutrients). But you should expect your electronic medical record to contain much more: information about your symptoms, lifestyle, the medications and supplements you take, past and present reactions to medication, and your concerns and even objections.

It takes a full range of data, when passed from your primary-care doc to a specialist, for that specialist to understand your baseline and build your specialized diagnosis and treatment. If that’s not done, chances are you won’t be as happy with the treatment process — or even the outcome — as you should be.

Unfortunately, a couple of recent studies reveal most records are not meeting those expectations. A 2014 study in the journal Plastic Surgery found that in a sampling of Canadian plastic surgeons, almost 25 per cent of the information fields on electronic records was incomplete, and 1.4 per cent was inaccurate — especially about current medications, medical history and medical allergies. And a new study from the University of Michigan’s Kellogg Eye Center found the symptoms and info patients entered on their pre-examination questionnaire and the information put into their records after talking with the doctor contained what the researchers called “notable differences.” Looking at the records of 162 patients, researchers found agreement between the pre-exam questionnaire and records for only 38 of the patients!

In one example, among patients who noted concern about glare (that’s a big deal when it comes to identifying cataracts and other eye problems), 91 per cent didn’t have mention of it on their electronic records. The cause for the omission wasn’t clear. One thing is for sure: As a patient, you have to be attentive to your medical records! Good docs don’t mind if you ask questions.

There are four ways you can increase the accuracy of your electronic medical record:

Repeat in conversation everything you’ve written down. Don’t just assume your handwritten notes will make it into your record in a timely fashion.

Be organized and have all your current info with you. That should include a list of your meds, supplements, recent test results, diagnoses from other doctors, and so on. Also bring a list of questions you want to cover during the appointment. This can generate pertinent info that belongs in your records.

Be assertive and collaborative. Let the doctor know if you still have questions. If there’s not enough time to address them, then ask if an additional appointment can be set up or if other staff members can answer your questions.

Ask for an electronic copy or a printout of your electronic records after every doctor appointment or in-hospital stay. Review the information, and then if there is an error in that record or something you do not understand in the instructions, ask about it.