Preventing medical mistakes by scrutinizing medical records

People may not know that they can review their own medical records. However, doing so can be crucial in being an advocate for yourself and preventing treatment mistakes and medical errors. As such, patients would be wise to request and review their medical records periodically.

Unfortunately, mistakes happen when it comes to these records. And these mistakes -- no matter how small -- can affect the care and attention patients receive. 

What types of mistakes to look for

When patients review their medical records, some of the most important mistakes to look for include:

  • Inaccurate test results
  • Improper contact information
  • Inaccurate patient information, like age, name and gender
  • Missing records
  • Typographical or transcription errors
  • Incomplete or erroneous condition descriptions
  • Incomplete medication history

As this article notes, these types of mistakes happen far too often. When they do, they can lead to misdiagnoses and other medical errors.

How mistakes happen

There are numerous reasons why mistakes happen in medical records. In some cases, the issue is simply a typo or something someone misheard while transcribing a doctor's notes.

In other cases, mistakes are the result of poor record keeping practices. Or, facilities might not properly train workers on updating or transferring records. This can lead to confusion, missed information and non-standard records that prevent others from accurately interpreting the data.

Cleaning up medical records

Patients and hospitals alike can work to ensure medical records are complete and accurate in an effort to avoid serious medical mistakes.

Patients can request and review their records and then ask the provider to fix any missing or inaccurate information. You may need to provide a detailed explanation of what you need fixed and why. If the provider does not agree that there is a mistake, they can deny your request with an explanation. Otherwise, the provider will make an update to the record.

Hospitals and medical workers can address medical record errors by confirming the information with a patient every time they see him or her. Doctors should also be diligent and clear in taking notes, while hospitals should regularly review their records systems to ensure there are no performance glitches or problems that can cause inaccuracies. 

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