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Medical record errors: What to do when you notice one

Anyone who has visited a doctor or undergone a medical treatment knows how much paperwork is involved. Medical providers must be meticulous in their documentation. Failure to do so can have wide-reaching and long-lasting consequences.

But the reality is, mistakes are often made on medical records. The patient may not notice the mistake, but that doesn’t mean he or she won’t be affected by it.

A recent article on CNN discussed the many types of potential medical record errors, which include:

  • Incorrect name, address, phone number, contact information
  • Incorrect diagnoses
  • Incorrect lab results
  • Errors of omission
  • Transcription errors

Any one of these medical record errors could have unintended consequences – and devastating results. The CNN article highlighted one story in which a man’s cancer was incorrectly named on his medical records. He had basal cell carcinoma (skin cancer), but his medical records indicated that he had renal cell carcinoma (kidney cancer).

It is not hard to imagine how a patient’s health may be affected by a medical record error.

What can individuals do to avoid a medical record mistake?

  • Request all medical records: It is advisable to request medical records on the day of the appointment, if possible. It is much more time-consuming to do this later.
  • Review your medical records: It’s not enough to simply obtain your medical records: You must make sure they’re accurate. Review all medical records for any errors.
  • Ask for a correction: Small errors, such as an incorrect address, can be self-corrected by marking the error with a pen and correcting. However, a more significant error – such as a wrong diagnosis – should be corrected with the hospital or clinic. You can call or write to the medical provider to request a correction.

Find out more about ensuring accurate medical records.

When someone is injured due to a medical mistake – which may include a mistake made on a medical record – it is advisable to discuss legal options with a medical malpractice attorney.