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Erroneous Information in Medical Record
Gynecologic Cancers | Last Active: Aug 12 7:07pm | Replies (18)Comment receiving replies
The medical record is a legal document. Once a note is signed by the doctor, it cannot be changed. When we started using electronic medical records, the inability to change a note after signing it was built into the software. But it can be amended, as described above.
I agree that inaccurate doctors’ notes are a problem, and too many doctors just don’t care. In my own practice, I have mixed up patients and I have forgotten information when writing a note at the end of the day. A solution that helped my note-taking accuracy was to type as much as I could while the patient was talking. And to try to make it less rude, I explain to the patient that this helps me write more accurately. I also use a laptop, so I can face the patient.
But even so, doctors’ notes are completely one-sided. Miscommunication and misunderstanding happen. Yet legally, doctors’ notes carry more weight than what a patient might say later. Not fair, but that’s the way it is.
Probably the best way to have a say in the accuracy of your own medical records is to read the note as soon as you can, and request an amendment (when necessary) as soon as possible. Sooner amendment requests carry more weight than later ones. And if you do this in the portal, it will be legally time-stamped and legally part of the medical record.
But the best solution to all this is to get doctors to really care about accuracy.
Replies to "The medical record is a legal document. Once a note is signed by the doctor, it..."
I appreciate your insight. Thank you.
I worry about an insurance company using the wrong information to deny coverage based on erroneous doctors subjective telemedicine assessment which were contrary to doctors who have seen me in person.
Original Medicare, under Mehmet Oz, is going to be using 3rd party companies to evaluate the necessity of doctor orders, require pre-approvals for procedures, surgeries, medications, etc. like Medicare Advantage plans do.
I have Original Medicare and like it.
Maybe this isn't the forum for the Medicare comment (?)
Doc,
Thank you for using your valuable time to reply here. It's great to hear from the other side of the desk. 🙂
A couple of my docs have hired a "scribe" who is present during the exam and types the doc's notes as the examination proceeds. A little weird to have another party in the exam room. Before the end of the appointment, the doc reads what the scribe has typed and verifies with me.
Might be expensive to hire a scribe, but probably saves time and aggravation, and ensures an accurate record.
Thank you, again! You sound like a caring doc. Bless you!
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In my last visit with my pcp in July, she used an “AI scribe” to take notes during my visit. It was the most accurate and complete recording of what I said and what she said. She was also able to have a conversation with me face to face without having her face in a laptop. The only inaccurate information was my weight which was input by the medical assistant who transposed numbers. I am very leery of all things AI, but this is one area where it seems to work.