medical records
Correcting inaccurate health records
As caregivers, most of us are not trained medical professionals. We are mostly family and friends who have chosen to care for our loved-one’s. Maintaining the accuracy of their health records seems like it should be the responsibility of healthcare professionals. Yet healthcare professionals can miss things. Incorrect medical records can have very bad near-term and long-term consequences.
The process for reviewing your loved-one’s medical records can be over overwhelming. I suggest trying this approach:
Get a picture
To know what is accurate and what need to be corrected, obtain copies of all medical records from your loved-one’s healthcare providers. You may request them in an electronic form that is convenient to you and may even upload the information to your personal health record application. Healthcare providers are required to provide this information to you free-of-charge. Be sure you receive copies of test reports, radiology images, prescriptions, vitals, and all diagnoses.
Medications
Check to see that all current (active) medications listed are all the medications your loved-one takes. Be sure that any past medications are marked as past (inactive). If your loved-one started taking a medication but had to stop because of an adverse reaction, be sure that the adverse reaction is noted in the allergies and intolerance section of the record and that that medication is listed as inactive. Verify all dosage information is also correct. Note any current medications are that are missing and be sure to add all over-the-counter medications including vitamins, supplements, and topical creams and ointments. Provide the healthcare provider’s office with a written list of all the correction requests. Ask for a new copy of the record to verify that the corrections were completed.
With any new medication prescribed, be sure the prescribing physician is using the latest list of medications, allergies, and intolerances. Even after this has been reviewed by the physician, it is always a good idea to check with the pharmacist too to be sure a mistake was not made. You may also use some online tools to check for potential drug interactions such as Drug Interactions Checker - For Drugs, Food & Alcohol.
Vitals
Vitals taken at a healthcare providers office may be accurate at that moment but may not be an accurate representation of a person’s overall health. For example, my blood pressure measurements vary significantly from one office visit to the next. Those once-a-year measurements are not enough to assess my health.
Look through your loved-one’s records to see if vitals such as blood pressure, heart rate, respirations, and weight look accurate to you. Whether or not they do, it is a good idea to start tracking vitals yourself. I recommend taking vitals at least once a week for healthy people and more frequently for people with chronic illness. You will use this data to establish a baseline of vitals so you can note changes over time that may be a significant sign of a health concern. Organize the vitals in a table or use a health record app. On your next office visit, present the data to the physician and ask that it be included in your loved-one’s health record.
Diagnoses and your observations
When you are reviewing each diagnosis in the health record, ask the following:
- Is the diagnosis correct?
- Has the problem noted in the diagnosis been resolved and if so, is it marked as resolved with the resolution date?
- Is the current diagnosis old and is it time for it to be re-assessed?
Look for any diagnoses that may be missing. Sometimes a diagnosis made at a past medical network doesn’t make it to the current provider.
Don’t be bashful about adding your own observations too. Your observation may be seeing your loved-one losing their balance, having intermittent headaches, getting a skin rash, or a change in their bowel movements. Let the physician know what you observed and when you observed it. If you took photos or vitals at the time of the observed event, be sure to show the physician. IF appropriate, ask that your observations be added to the health record.
Behavior and mental health
Changes in someone’s behavior such as irritability, lack of interest, excitability, and lack of focus can be signs of significant medical issues. When we care for an adult or child who has limited verbal abilities, these behavior changes may be the only signs of a serious problem such as an adverse reaction to medication, a neurological issue, a hormonal imbalance, or an arterial blockage. They may also be early warning signs of a mental health condition such as depression or dementia.
Whatever you observe, be sure to document it. Give the date and time and take notes of what you observed. Include what your loved-one ate that day and any medications taken. If your loved-one tolerates it, take their blood pressure and heart rate. Now when you see the physician, you will have some information that may be helpful in selecting tests for a better diagnosis. Even if the healthcare provider does not recommend testing, you may ask that your observations are put into your loved-one’s health record.
You are critical to the process
Sometimes we may feel like we are intruding in a healthcare providers domain by asking questions and offering our own information. In reality, you are critical to the process of caring for your loved-one. You observe so much more in thousands of hours you are with your loved-one than a physician can make in 20 minutes. The information you track and report is essential to your loved-one’s health. You are a key member of the healthcare team.