The Medical Record Hangover!

Medical records should be an accurate account of each visit, test or procedure and nothing else…emphasis on accurate.

The problem is that there really is no appreciation in the medical business for just how much damage can be done from medical record inaccuracy. When is the last time you looked, I mean really reviewed, your medical records for say the last five years? If you found something that wasn’t really true would you demand that it be corrected?

I’ve had a couple of classic instances this week. A person I was helping with a life insurance application had a weight on their insurance exam of 234. This seemed reasonable to me since they were a long time client and five years ago their weight on their application was 228. Three days after the most recent exam they were weighed at the doctor’s office and the weight recorded in the records was 260, a 26# difference in three days.

This was brought to the doctors attention but no note of the discrepancy was entered into the records, no reweigh was done, and there was nothing done to change the obviously erroneous weight in the records. This person just shook it off and went on with life. When the exam and records hit the insurance company, even though it was obvious one of the two weights was in error, with no way to tell, they just averaged the two weights bumping this client’s rates up by two tables, 50%.

The other instance is probably one of the most common, a carryover of social history without updating the information. This is where things like family history, smoking, drinking, drug use and so on are noted. Most doctors will ask those questions the first time they see you and note them under social history. Then they never ask again, and even if there is a change that is discussed, the next time you see them the old social history is drug forward onto the current page.

This came to light with a client who has not had anything to drink in a very long time. They quit and have been a clean and sober member of AA since then, but their social history still said “drinks occasionally”. Well, that is a show stopping decline when it comes to life insurance. A member of AA that still drinks isn’t going to get approved for life insurance. Fortunately for this client the doctor was willing to enter a rebuttal of that entry in his records. That’s rare though. Most doctors don’t want to admit they’ve been in error.

Bottom line. Review your records. Much is made about the need to review your credit report because of all of the misinformation that can be contained there. The same holds true, and can be just as damaging, with your medical records.