A woman walks through a doorway into a digital world full of information in floating squares.

Medical Records and History - Are They Current and Accurate?

When we put our lives in the hands of medical providers, the information gained from our conversations, tests, procedures, surgeries, and prescriptions are recorded. It is imperative that this medical information is accurate.

The value of patient portals, where patients and medical providers in that network can access current and past information, is of great importance as the information is readily available and literally at their fingertips.

Patient portals are common

My doctors use a shared online patient portal which allows me to schedule non-emergency appointments, send messages, access test results, and review office notes and my medical history.

This makes me feel much better knowing that every doctor has the most up-to-date information about my health. While I may check office notes, I do not usually check the history information.

How many of us take the time to review our medical information and history that is kept on patient portals? Though it is easily accessible, how many really take the time to check it regularly? Do we assume that it is always accurate and has every surgery, test, prescription, and allergy noted?

I certainly thought that was the case until... It wasn't.

Necessary information was missed

Normally when I have an appointment with a doctor, I will see a physician's assistant (PA) or nurse first. They will ask questions, write my responses, go over past prescriptions, and review any changes. I never really thought about the accuracy of this until 4 years ago.

I had been seeing a specialist for hip and lower back issues, and it was determined that I needed a hip replacement. I had specifically sought a surgeon who could perform an anterior versus lateral approach procedure. The anterior (front approach) spreads out the muscles while the lateral (side approach) cuts through them.

The anterior approach is touted to be a faster recovery, and I was all about that.

A pretty big miss

About 2 weeks before my scheduled surgery, I went for my final pre-op appointment with the surgeon. At the end of the appointment, I asked how my urostomy would be handled and if I needed to bring anything.

The surgeon responded, "Your what? I did not know you had a urostomy." I explained that I always highlight it on my paperwork when I have my initial appointment with a doctor and was sure I did that at his office. I had mentioned it at every visit when the PA saw me first.

Long story short, as my right hip was the problem, I would not be able to have the anterior procedure as no one had read this very important tidbit of information in my file or recorded it again during my visits.

Obviously, I was very upset. But it would have been worse had the surgeon found out when I was on the operating table in surgery, as the procedure would have been canceled due to the time needed.

That situation made me much more aware of the fact that doctors may not take the time to actually read past history due to time constraints. Still, in my humble opinion, important information needs to be said to the doctor in case the PA or nurse has not noted it again.

Recurring inaccuracies

Recently I needed to see an ENT, ear, nose, and throat doctor - due to continuing ear issues. I saw a message for my follow-up appointment and decided to review the notes and my history again.

I was surprised when I read through and found a few inaccuracies. For instance, it said I had a urostomy revision in 2014 as well as a urostomy created.

No, I have never had a urostomy revision. It stated that I have PONV - which is post-op nausea and vomiting, which I have also never had.

I decided to make sure that I continue to review this information often and bring any inaccuracies to the attention of my medical providers. I did that at my next appointment and asked that they take the time to review my history. I also reminded the doctor not associated with my cancer team that I have a urostomy.

Expect the unexpected

Something also to consider is that emergency personnel have access to patient information on some portals, which can be valuable in life-and-death situations.

I now check my office visit notes, history, prescriptions, allergies - within a few days of each appointment.

Keeping your medical information correct

While I am certainly not saying that everyone has errors or inaccuracies in their records, with the short window of time that it seems we have to see medical professionals these days, the information must be correct.

I encourage everyone to take the time to review your information to ensure the accuracy of your medical history and office visit notes. Also, family medical history is important.

Has anyone else found important information missing or inaccurate in their records? Let us know in the comments below or start a thread in the forums!

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This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The BladderCancer.net team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

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