A Right to Your Records

Posted by nurse on September 2, 2011 under Critical Care, patient health | Be the First to Comment

Ever wonder what is on those charts? Patients have a right to their records and copies of their records, and also have a right to see what summarized information makes up the bulk of their history. A patient should be able to view and comment upon their chart in conversation with their doctor. Are current health assessments correct, were they in the past, and were details as communicated to the patient about what choices were available really shared? When all the principals are in the room the answers to these questions can be surprising.

Any patient being treated today could end up in court. Medical malpractice lawsuits are real. The decisions to pursue legal action occurs when attorneys and the patient have the best information possible about the course of treatment. Supporting signatures or emails can be added to the patient’s own records regarding these matters. A patient should begin keeping a diary of every hospital or clinic visit as soon as possible after diagnosis, or even before.

Patients can often spot where one doctor might make an assessment about patient care needs working from assumptions about patient wishes gleaned from concise chart notes. But a history can me made up of hundreds of informational exchanges with and where subsequent doctors might ask if at a specific point in time information was lacking about other therapies, treatments,and procedures. When an evaluation requested, at which point in the medical treatment course, and by whom?

Since the patient is the one most familiar with all the details of the treatment history, they are the most likely ones to post errors and elisions of fact. But when a patient passes from one doctor to another, one staff of nurses to another group, and one department of a hospital or another, the facts supporting certain recommendations and treatments can get mangled or deleted. The patient can annotate their own files with the rationale and supplemental information need to make sense of it.

One small detail can be hugely significant. The details should be recorded when staff are handing off critical portions of recovery to other departments can be crucial to understanding a physician’s planned path to patient wellness. Multiple rehabilitation strategies might be viable, for example. But setting forth in writing what the reasons are for the order in which the patient will undergo the therapies required. These include occupational therapy, physical therapy, woundcare, and speech therapy.

Much is made by nurses and administrators about the need for accurate completion of paperwork. The nurse should not be afraid to review her notation on the procedures orders with patients or make these comments known to the doctor. Patients will not welcome medical coverage from a provider which shields it medical files from the patients themselves. And by the time a patient undergoes a treatment or application of a pharmaceutical remedy that is not right, it is already too late.

Many patients will want to look for an application online that tracks and charts patient history. The patient will want an information rich timeline showing the progress as well as records rages and readings from various tests and checkups. Many specialists want to review the case later and see which therapies answered the condition well after related former therapies and courses of medication have been tested and found wanting.

Patents who move from a local doctor to doctor’s offices in another state, or patients who see a doctor while traveling should not have wait for the consulting physician to search for past records.

At some future point in time, past blood test results and tox screens, as well as other types of tests will be relevant in a discussion of other conditions or medical health problems. And being able to plot out the treatment in hindsight may hep a patient handle their upcoming medical challenges as well.

Interested patients should be able to track and forecast medical costs, commuting and wellness diets using a file including their medical journals of treatment and the outcome of each visit. Medicine is a revisionist science at times. In later phases of diagnostics, a new pair of eyes may review the past treatment history and intercede with questions that break the case wide open.