<today's guest blog for Patient Safety Awareness Week is by Lisa Fenichel, MPH, a healthcare advocate and educator. Lisa sits on the Massachusetts Health Information Technology Council and is a member of the Washington, DC-based Consumer Partnership for eHealth. She can be reached at firstname.lastname@example.org.
Inspired by the elegant simplicity and undeniable utility of Dr. Atul Gawande’s checklist for improving surgical safety, I decided that I should focus this blog for Patient Safety Week on something similarly concrete, useful, and achievable. Something that patients themselves can do that could dramatically improve their safety, which is: get a copy of their medical record.
For all the years I have devoted to learning about and parsing the often complex issues that arise at the intersection of electronic medical records and consumers and patients, one basic idea persists: our medical record is one of the most important tools that exists to promote and ensure our health and well being, and most of us have spent little or no time considering it. A medical record is a living document, both current and historical, and it should reflect fully and accurately the care, health status, history, medications, lab results, diagnoses, and conditions of the individual whose record it is.
These are the basic steps*:
- Collect: Patients should request copies of their medical records in whatever form is most convenient (and available) – new requirements that they be available electronically are already in effect for certain providers, and that will become the norm very soon.
- Inspect: Review your records for completeness and accuracy.
- Connect: Start a conversation about your records with your healthcare providers and discuss anything in your records that you believe may be missing or inaccurate.
- Correct: Make sure any needed corrections are clearly noted in your records. (If your provider is unable to change the record itself, you should be able to add a written amendment to the file explaining the change[s] you think necessary.)
Taking these steps would represent a huge leap forward both in becoming engaged consumers and patients and in promoting healthcare safety. For example, if a record includes a prescription that the patient did NOT fill, or was not able to take; or incorrectly describes the patient’s health history with a diagnosis that was ultimately ruled out; or does not include important health information, such as significant weight loss or frequent headaches, then the prescribed course of treatment for a new ailment could easily be compromised — or even be dangerous.
By noting such discrepancies and speaking with our providers about these and any other concerns or questions (after all, just having one’s medical record does not mean it is easy to understand), we are helping ourselves and our providers move toward a more engaged relationship and a greater understanding of our health and our healthcare needs. That engagement alone should make for better and more informed decisions — for the patient and the provider — which should lead to safer, more efficient, effective, and appropriate care, and, therefore, healthier, fuller lives.
So, to celebrate this important week (though any week will do), request a copy of your medical record, read it carefully, talk to your doctor about it, and ask questions until you feel confident that you understand it and that your doctor understands you.
After all, there is no time like the present – Patient Safety Week — to set the record straight: your medical record, that is.
* In the interests of simplicity and brevity, I have not gone into the details concerning the rules and regulations regarding medical records (e.g., copying costs, time frame, mental health records, corrections, and amendments). There are many helpful resources to refer to for more information; including Georgetown’s Center on Medical Rights and Privacy; their Massachusetts guide starts here. -Lisa Fenichel