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Errors in my medical report - Anonymous

Posted: Mar 29, 2012

I wanted some opinions, please - what would you do if you viewed one of your medical reports on line and discovered it was full of errors? I fell at work several months ago and needed surgery on my ankle. As it was work related, I was requested to have a closing exam by an "independent" provider chosen by my employer's industrial insurance. The final report was available for me to review through their website and I did so today. It is full of mistakes, ranging from an incorrect date of service, a certain medical word being misspelled several times, reference to my pain med prescription which is wrong and some other pretty blatant medical errors. There is not an attorney involved. They closed my claim which they probably would have done anyway but I don't like the fact that my medical info is all wrong. I dealt with it by reporting it in writing and providing documentation to all parties concerned but I thought it would make an interesting discussion. I'd like to blame VR but I know that the doctor dictated the report and some MT somewhere transcribed it. I'm thinking that this could be a liability issue for someone. Please share your thoughts, thanks.

Request that the original report be corrected - RHIA

[ In Reply To ..]
You have a right to request that this be corrected. They do not have to correct it if they disagree with your corrections, but if it is a date of service and incorrect pain med information, they should not have a problem with it. If they choose not to correct it, they have to tell you why.

Focus on correcting significant errors, i.e., something that would lead to future problems for YOU. The date of service would be appropriate and the type or dosage of your pain medication, or the length of time you had taken it, would be appropriate corrections. Wrong site, wrong service, incorrect history, incorrect exam findings would be appropriate. The spelling errors are not a significant issue if the meaning of the words is still clear.

I'm not sure how you know an MT transcribed it. Even if there had been a sign-off at the bottom, it could have been done by VR. It could also have been generated by the doctor himself.

RHIA - Anonymous

[ In Reply To ..]
However the report was generated, it's a mess; all the things you mention exist. I did what you suggested and requested to have the corrections made. Thanks for your input.

Actually, it sounds fairly clean compared to many I'm - hearing about. Physicians typically

[ In Reply To ..]
seldom had to make their records available to others before, and bad recordkeeping has always been rampant. On top of that, now that offices are putting in SR systems, many dictations go into the files totally unedited. (!) Liability? You betcha! Potentially BIG time liability exposure--IF you're still alive or well enough to be able to care about anything beyond your immediate suffering.

I haven't done it yet (2 visits total to my "new" PCP in the past 4 years), but we have a right to view most of our medical record and should expect that we really, really need to. In future, all EHRs have to include a function for patients to enter their own data on patient-entry screens (carefully segregated from the clinician-entry functions, of course.) Also demanding and following up to confirm that certain pieces, like correct drug names, actually make it to their screens will probably be necessary.

Something I'll definitely be on the lookout for is disorganization to the point that it compromises ability to find information. I don't need several days of misery and an extra week's worth of hospital and test bills because the doc didn't notice that I once had acute kidney injury from unknown cause. Too many physicians don't have the time or inclination to study sloppy reports carefully word for word and end up hoping to pick up additional info along the way, presumably by osmosis when they don't know enough to ask the right questions. If I see them in my record, I'll definitely complain about any of those page-long paragraphs that hide details like nuts in a fruitcake.

An expression - Anonymous

[ In Reply To ..]
The expression "close enough for government work" comes to mind after seeing my report. If the misspelled words were the only things wrong, I would have let it go, but there's so much more.

Where was QA on this one? - JW

[ In Reply To ..]
I can't stresss enough that accuracy comes before speed to get a report done. In this day and age, I don't think it matters all that much, again the dollar is the bottom line. Sad. I hope you can get it straightened out.

Why would there be QA at a doctor's office??? - Maybe his wife did it

[ In Reply To ..]
Why would there even be an MT at a doctor's office? It was probably done by his wife or someone in the front office like an MA or receptionist. If this doctor is doing opinions for WC, he is willing to accept pay so low that he can't afford to pay an MT to do this.

He is responsible for the medical errors, not the typist. How could QA even know what those were?

Thanks - Anonymous

[ In Reply To ..]
Thank you to everyone who took the time to answer. Actually, I had issues with the exam itself before the report was made available. I'm happy to report that the WC peer review board took this seriously and has already addressed those concerns, I trust that my exam report will be corrected as well. I don't know how they deal with these things, but he could be fined/barred from performing IMEs. I agree, the doctor is responsible for his medical errors and could have at least proofread the thing before he signed off on it. I would think that would be especially important in cases like these when sometimes attorneys are lined up around the block with dollar signs in their eyes. The mistakes in my medical/medication history were made because he was too damn arrogant to ask me for any information and assumed that he knew it all. Blowing the whistle probably will not change anything in regard to the status of my claim, but I'll have the satisfaction of knowing that sometimes there is justice in this world.

I wouldn't request anything I would demand the report be fixed - Find out who transcribed it

[ In Reply To ..]
I am held to strict QA standards for every report I transcribe. I expect my record to be held up to that same standard. I would be take this up the food chain right to that pissant Robber Davenport.

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