Editor’s Note: Dr. Richard Radnovich is a National Pain Report contributor who has been writing on the patient-doctor relationship. Today, he addresses the issue of patients records.
I received an email from a reader who had a question and concern about what is in her medical records that may be keeping her from getting the care she deserves.
Patient: Medical records and “telephone conferences with past providers” are not always accurate. There HAS to be some recourse, NO? I asked my PCP WHAT is in my file and she coyly said she didn’t know. NO-ONE is addressing the problem of inaccuracies, bias, subjective opinions, and the denial of needed pain medicine. I have to have a way to see and correct whatever is in my file that is preventing me from receiving pain medicine.
Dr. Radnovich: You have every right to see what is in your file. The information in your file is YOURS (well the content is, not the paper itself). No provider can keep you from seeing it.
Reviewing medical records is not a necessity, but if you are having issues, it is reasonable to see what they say. Go to all the places that have given you care and get a copy of your medical records.
For physicians in private practice, simply ask the receptionist for a copy of your office notes. Do not make a big deal of it, the doctor does not even need to be involved. If you have been a patient for years with a particular office, you do not need chart notes going back forever. Maybe just the last year, or from around the time the relationship with the doc went bad. Just tell them you want a copy for your records.
For hospitals, call the medical records department (sometimes called Health Information). If you have been an inpatient (stayed in the hospital overnight), most of the time you really do not want ALL the records. What you need is the “discharge summary” and the “admission history and physical” for each time you stayed. If you have only been in the ER, get just the ER notes for each visit.
You should also be able to see your board of pharmacy report. You might need to call your state board of pharmacy to get a copy of your profile. This profile is available in most states and shows all the controlled substances that were dispensed to you. You should also contact your pharmacy itself and get a print out of all the medications dispensed in your name.
Once you have these records, go through them line by line. Look for significant problems. If you had your gallbladder out in 2001 and somewhere it is noted as 2003, that is not significant. But if the pharmacy monitoring program documents that you were given #300 Norco but you never get more than #120, that is significant. You want to pick your battles. Choose to correct the things that make a difference.
If any of these providers try to keep information or records from you, remind them of their responsibilities under the Health Information Privacy Protection Act (HIPAA). If you find significant errors, your medical provider, pharmacy or hospital cannot simply remove bad information. But they are required to correct the data if possible or enter your corrections or comments. More information about your rights can be found here: https://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/medicalrecords.html
Have you tried to get a copy of your records and review them? How did you handle it? What worked and what did not? Let us know, maybe you’ll be helping the next Chronic Pain Patient.
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Dr. Radnovich is a nationally known chronic pain physician and researcher. Here’s more information about him and his practice.
Questions for Dr. Radnovich? Email him at firstname.lastname@example.org