What's in the file

Don't be locked out of your medical files.

Do you know what's in your medical file?  Do you know what is being documented for future reference?

Most of the time whatever is in there is fine.  But you should request to see your files to ensure that there isn't misleading information.  My personal example is when I was in the hospital in 2010.  Not knowing exactly what was causing the excess fluid in my heart area, I was diagnosed with congestive heart failure. As it turned out, it was due to an extreme flare of lupus nephritis.  I did speak to the physician to have that diagnosis removed, but it reappeared when information was transferred to my new medical group.

Healthcare has gone through a lot of changes in recent history.  More than likely it will change again and again.  Ensure your records are accurate to avoid costly errors.

The following article was written by Dr. Wen who incorporates patient involvement in her practice. 

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Smart Patient Takeaway:  This is a great tool for patients who want to be sure their records are accurate, or have interest in seeing what their doctor is recording about them. (Hint – that should be everyone!) In addition, it sets the stage for a good partnership with your doctor.

Be sure you have the information you need to access your records from home, too.  Then, each time you have a new appointment, or something changes in your record, log in to see what has been added or amended in your record.

If your doctor doesn’t let you share in the input and review process on your medical records, tell him or her you would like to participate in your record keeping, too.

Additional Idea:  Using your smartphone, or a small handheld recorder, record your appointment with your doctor.  This will allow you to listen back later to confirm that you remember new instructions and information. Tell your doctor you’ll be recording the session – politely, of course – but don’t ask permission. It is your right to record the session, and it’s a smart tactic, especially when information is easily confused.  (Asking for permission provides the opportunity for the doctor to say “no”.  Or, as Gramma used to say, “It’s easier to beg forgiveness than ask permission.”)

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