What’s in your record?

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Did you know that you have a RIGHT to review or receive a copy of your medical record? The Privacy Rule under HIPAA gives you the right to inspect, review, or receive a copy of your medical record.

I never dreamed I would need to review my medical information. After multiple surgeries and dozens of doctors I realized I kept getting asked about numbness in my leg. There was no numbness but some tingling. I finally requested my medical records from several doctors offices and BINGO I found the culprit. A doctor had listed a diagnosis for neuralgia in my medical chart. That diagnosis continued to follow me for years until I spotted it and began asking questions. In a strange twist of fate, I later ended up with neuralgia. I can’t escape that word in my medical record. I learned a hard lesson though. You need to understand that your medical record is not always accurate.

Why did I even care? Everything in my medical record was reported to my health insurance. As is yours if you have insurance. One small misstep that goes unnoticed but is continually reported could be costing you. If you have received a diagnosis but have not been treated for it will your insurance think you are refusing treatment? Or could it impact the cost of your premiums. Are you the dreaded non compliant patient?

Things get really tricky when you say something off color while at an appointment, maybe your having a bad day, and it gets written down in your medical record. If the doctor or medical team think it is important enough to note in your chart, every other doctor, and your insurance provider, will have access to that as well.

 What happens when you find an error? Make a point to set it right. You can request a change or amendment to your record through the provider or health plan. If they disagree with your change you can submit a statement of disagreement that must be added to your record.

 Aside from checking your medical record for accuracy, you should be checking it for education. Have you ever wondered if you truly understood what the doctor was explaining to you during a visit? Looking over your record is a chance to see YOUR medical directions in writing. It is an opportunity for you to find key words to research if you don’t understand and to make a list of questions for your next visit.

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