A message from TWW attorney, Phillip Warren:
Like many people, you may assume that you know what information is contained within your medical records, even though you've never seen them. Each time you visit your doctor, you see the nurse write down your weight, blood pressure, and medications. Initially, you may also have to fill out forms about the reason for your visit and your medical history. You see the doctor writing things down in your chart, but what exactly? Is the doctor noting your complaints of neck pain, your difficulty sleeping, your recent weight loss, or that pesky mole on your arm that itches constantly? Don't count on it. The truth is that we pay more attention to our sales receipts than to our medical records. While being charged for items you didn't purchase won't kill you, not knowing what your medical records say about you just might.
Medical Records Often Contain Mistakes
I represent people who have been physically injured by the carelessness of others. I have reviewed thousands of pages of medical records for hundreds of clients. A common theme that I have observed while reviewing medical records on behalf of these clients is that medical records contain mistakes and don't always reflect my client's real problems. There are many reasons why we do not review our own medical records. Frankly, some of us have never thought of it. Generally, we trust our medical providers to keep up with our health information and assume that we wouldn't understand the terminology or test results in our records anyway.
You Can and Should Request Copies of Your Medical Records
We may worry that requesting a copy of our records will be insulting or viewed as a challenge to our doctor's medical authority and knowledge. Or we are just scared to learn about our own health and prefer to practice avoidance behaviors. Almost all of us think that if we don't hear from our doctors, then there are no problems, the “no news is good news” assumption. “No news” does not always mean good news. Medical records can contain information that you need to know, but your doctors have failed to tell you. For example, if your doctor sends you to a specialist for an examination or to a lab or imaging center for tests, these entities report back to your doctor with a fax or a letter. The specialist, the lab, and the imaging center send your results and their findings to your doctor, but not to you.
Sometimes Diagnoses or Recommendations Make It to Your Records, But Not to You
I have firsthand knowledge of doctors receiving reports of findings and forgetting to let their patients know about these results. I know of a gentleman who went to his doctor concerned about the color of a spot on his skin. The doctor performed a biopsy of the spot and sent it to the lab for testing. The lab test came back positive for skin cancer, melanoma in fact, a very deadly form of skin cancer. Fortunately, the cancer was caught very early. Unfortunately, in this case, the doctor neglected to notify his patient. His error was the result of a filing mistake in his office. The lab results were discovered in the chart after the patient passed away from the ravaging effects of the melanoma. While this makes for a very viable medical malpractice claim, I can assure you that the family would much rather have him back. I'm sure your loved ones felt the same way about you.
In another example, a man complaining of shortness of breath, was referred by his doctor to have an exercise stress test performed. The cardiologist who performed the test discovered that the man had very serious coronary artery disease. Coronary arteries directly supply blood to the heart. The cardiologist faxed his findings to the man's doctor along with his recommendation that the man required immediate medical attention. The fax didn't make it to the man's medical chart for a week or two. Sadly, he died before the doctor took any action on the cardiologist's fax. Needless to say, the doctor was very upset and remorseful for what happened with his patient.
Medical Records Can Sometimes Be Just Plain Wrong
I represented a woman for injuries she sustained after hurting herself on a business property. In reviewing my client's medical records, I was shocked to discover that her doctor had labeled her as a malingerer and a drug seeker. A malinger is one who exaggerates or fakes medical injury for gain, monetary or otherwise. After bringing this to the attention of my client, I contacted the doctor about these allegations. Come to find out, my client's name was similar to that of another patient and the wrong information ended up in my client's chart instead of the patient's who had the drug problem. The doctor was apologetic and quickly agreed to fix this error. However, had this record not been corrected, it could have had a drastic impact on my client's claim for injuries.
Sometimes Reported Symptoms Are Not Documented In the Records
Also, medical records may not contain the information you have provided to your doctors. Too often my clients have been surprised at what ended up in their medical chart versus what they said to their doctors at an office appointment. A client told me that she went to her doctor about her headaches, neck pain, shoulder pain and knee pain. She saw the doctor taking notes, and said that they also talked about the weather, what so-and-so person is doing these days, the restaurant that just opened up downtown and so forth. When my client obtained the office note, her doctor had simply stated “the patient is here today complaining of knee pain”. This example of incomplete information in a medical record creates a problem for a patient seeking recovery for injuries to her neck and shoulder from a rear-end vehicle collision.
The problem arises because insurance companies will argue that the absence of a complaint in a medical record means that the patient was not having any problems with that body part. Due to the doctor's incomplete charting, she has no medical proof that she complained of neck and shoulder pain on that date and makes it further difficult to relate those injuries to the automobile accident itself.
Discrepancies In Your Medical Records Can Be Harmful
From the extreme examples of losing an opportunity to fight cancer and heart disease to the disastrous impact that misinformation or missing information can have on your injury claim. So what should you do? You have the right to access your medical records, so request them from your doctors.
How to Request Copies of Your Medical Records
Contact your doctor and ask what the procedure is for you to receive copies of your chart. Your doctor can charge you for these records, but the state of Florida limits the amount that you can be charged per page. If your doctor refuses to provide your records, contact the Florida Department of Health and ask to file a complaint. Obtaining your medical records will allow you to catch misinformation and mistakes, plus you will be able to determine whether your doctor is really listening to your complaints. Reviewing your records will allow you to identify what specialists have discovered about your health and what treatment they have recommended. At the very least, you will signify to your doctors that you are an informed and proactive patient who values what their records say about you.