Because of technological advancements, medical information and records are no longer found solely in the treating doctors office, but are often transferred electronically to other treatment providers, insurance companies, law enforcement agencies and government programs. As a result, should incorrect information be included in a specific patients file, the consequences may be much more far reaching than ever before.
Almost all adult patients have the legal right to review their medical files. Upon payment of reasonable clerical costs, they may also receive copies. Of course, access to ones health records may still be denied if the doctor, therapist, or other health care provider determines that disclosure of information could result in the particular patients confronting an unnecessary risk.
If after reviewing their medical files, patients discover that information is incomplete, inaccurate, or just plain wrong, they may request that changes and/or corrections be made. Although the health care provider will often comply, this is not always the case. Treatment providers who either believe that the patients file content is correct, or lack the authority to amend it, may refuse to modify, delete or expand a contested medical report or other type of professional note.
Luckily, almost every patient has the legal right to submit a written statement of disagreement that must be included in his or her medical file. According to existing law, the treatment provider may limit such statements to no more than 250 words for each disputed claim. The health care provider may also submit a written rebuttal which, along with the patients written statement, must remain a secure part of that patients medical file.
Current federal and state laws allow health care providers to transfer their patients confidential medical information in a manner that never existed before. For that reason, in order to ensure that transferred information is accurate and complete, it is important for every patient to review personal medical files and, if necessary, request that corrections be made.