Take Control of Your Health Records

Gretchen Becker Health Guide
  • A recent study has shown that errors can appear in your electronic medical records because of copying and pasting.


    I don't find this very shocking. Errors can appear in your old-fashioned medical records too, for many reasons.


    Your doctor might have misinterpreted what you said and written it down as gospel truth. For example, if you were put on a high-carbohydrate diet and prescribed a sulfonylurea, a combination that can cause weight gain, and you then gained weight, your doctor might have written "noncompliant" in your record, assuming you were cheating on the diet rather than the real reason: the prescribed diet and drug caused the weight gain even though you followed the diet to the letter.

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    Your doctor might have omitted some information he or she thought was unimportant but that turned out to be critical. Papers might have been lost.


    We have to accept that human beings are not perfect. We all make mistakes. I think I made one once.


    I was once screened for a study of vanadium at the Joslin Diabetes Center in Boston, one of the best diabetes centers in the world. I was rejected on the grounds that my blood glucose levels (BGs) went too low and they were concerned that the vanadium would make them go dangerously low. "I don't like this 20" the doctor said after the nurse had downloaded my meter.


    I told her I'd never had a 20 in my life, but she obviously didn't believe me.


    It turned out that the nurse who had downloaded my meter didn't understand the software and had merged my records with those of a previous patient. But they'll assume a patient was wrong before they'll believe that a medical person was wrong.


    Later, at the same institution, I was weighed by a nurse trainee. The weight was 130.3. The nurse wrote down 133.


    Lab tests are also not always spot on. Every lab may have a slightly different method of measuring something, producing a slightly different result. I was in a study at Joslin that had me give blood at Joslin and then 2 weeks later give blood at Womens & Brigham, then back to Joslin 2 weeks later, and then W&B again.


    Joslin said my HDL was 45. W&B said it was 55. Then Joslin said 45. Then W&B said 55.


    Now I don't think my HDL was bouncing around, coincidentally always 10 points lower at one lab than at the other. I think it was different tests or different people doing the tests. But doctors sometimes make prescribing decisions on the basis of just one test. I once had a doctor who wanted to increase my statin because my LDL was 71, and she liked to have LDL under 70 for anyone with diabetes. I said no. One point is meaningless!


    What this means is that we really need to take charge of our own health. Always ask for copies of your lab reports. Especially if you change doctors often, the records could be lost. I know it's now a pain to get your own records because of HIPPA. It used to be that the doctor simply checked "copy to patient." Now I have to go to the records office once a year and sign a release to get my own records!


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    But it's worth it. You can see how the numbers change through the years, if they do, look for patterns, and then try to figure out why. For example, if you're told your lab tests for kidney function aren't good, you can go back and see what the same tests, which you might have ignored in the past, were 5 years ago. Are you bouncing around, which might be for various reasons not related to kidney function? Or have you been seeing a steady increase in the numbers?


    It's an additional burden to have to monitor our own records, but it's worth it. When mistakes are made, we are the ones who pay the price.


Published On: May 28, 2011