Let's Answer All the Questions You Have About Your Healthcare Records. Article 1 Blog Series
A practical guide to understanding, correcting, and protecting your health information.
Series Introduction
Most people assume their healthcare records are accurate until something goes wrong.
Maybe your patient portal shows a condition you've never had. Maybe two patients were accidentally merged. Perhaps you are staring at complex lab results without any context, or you’ve spotted personal details that simply aren’t right.
Your medical record is the single source of truth for your care, guiding every prescription, procedure, and clinical decision made by your healthcare team. While electronic health record (EHR) systems have revolutionized patient care, they are not immune to human or technical error. The good news? You have legal rights to access your health information, healthcare facilities have dedicated processes to handle discrepancies, and most errors can be resolved.
This blog series breaks down the most common questions surrounding health records, offering practical steps to help you understand, correct, and protect your medical history.
Article 1
FAQ: "Why Does My Medical Record Show Something That Isn't True?"
Common Discrepancies You Might Spot
When reviewing your patient portal (like MyChart) or requesting physical copies of your chart, you might encounter several types of inaccuracies:
Unfamiliar Diagnoses: Historical conditions or family medical histories recorded as current active diagnoses.
Inaccurate Medication Lists: Discontinued prescriptions still listed as active, incorrect dosages, or missing drug allergies.
Demographic Errors: Misspelled names, outdated contact details, incorrect primary insurance information, or wrong emergency contact numbers.
Unrecognized Encounters: Listed visits, procedures, or telephone consultations you do not recall having.
Overlay or Mixed Data: Clinical notes, lab results, or imaging reports that belong to an entirely different individual.
How Errors Enter the Electronic Health Record
Healthcare data is generated from a vast, complex network of contributors across the care continuum. Information flows continuously from:
Primary Care Physicians & Specialists: Documenting clinical assessments, impression notes, and treatment plans.
Nursing & Clinical Staff: Recording vitals, triage notes, and bedside observations.
Registration & Patient Access Teams: Inputting insurance details, social security numbers, and demographic data.
Diagnostic Labs & Imaging Centers: Transmitting digital diagnostic data into your portal.
External Health Systems & Health Information Exchanges (HIEs): Sharing records automatically across regional networks.
With so many touchpoints, errors usually happen in one of three ways:
Manual Entry Errors: Busy clinicians selecting the wrong drop-down item, mistyping a code (such as ICD-10 or CPT codes), or pasting prior progress notes into a new encounter without updating details.
Identity & Matching Issues: Two patients sharing similar names, dates of birth, or addresses can lead registration staff to open the wrong chart, resulting in a "mix-up" or merged chart.
Interoperability & Data Import Glitches: Automated external data imports from another clinic or health system can misalign data fields or bring over outdated historical information without proper clinical verification.
Step-by-Step: What to Do When You Find an Error
Document the Discrepancy Clearly: Take a screenshot of the patient portal screen or highlight the precise section on your printed summary. Note the date of the encounter, the provider’s name, and the exact statement or code that is inaccurate.
Contact Health Information Management (HIM): Reach out to the hospital or clinic’s Medical Records or HIM Department rather than just calling the front desk. HIM specialists are specifically trained to handle data integrity and chart corrections.
Submit a Formal Request for Amendment: Under HIPAA guidelines, you have the right to request an amendment to your medical record. Request the facility’s official Medical Record Amendment Form and submit your documentation in writing.
Maintain Your Records: Keep a personal log containing the date you submitted the request, copies of all forms sent, and the names of any staff members you spoke with.
Important Nuance: Clinical Opinions vs. Factual Errors
It is vital to distinguish between a factual error and a difference in clinical opinion:
Factual Error: An incorrect birth date, a wrong lab result attached to your chart, or a medication you were never prescribed. These are straightforward and routinely corrected or amended by HIM departments.
Clinical Opinion: A physician’s professional judgment, diagnosis, or impression recorded during an evaluation (for example, a doctor documenting "symptoms consistent with chronic fatigue").
Under healthcare privacy laws, providers are generally not required to change a recorded clinical judgment simply because you disagree with it. However, if the provider declines to alter their note, you have the legal right to submit a formal Statement of Disagreements, which must be permanently attached to that specific section of your medical record for future providers to see.
Have Questions About Your Health Records?
Managing your health information is an essential part of advocating for your overall well-being. Whether you are preparing for a specialist visit, transitioning to a new health system, or simply keeping tabs on your portal, understanding your rights makes all the difference.
Have you ever found an error on your medical record? Drop your thoughts or questions in the comments below
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