Medical Record Accuracy

 

Transcript: It is important to make sure your medical records are accurate. First you might be wondering, what is a medical record? A medical record is anything that your doctor, or nurse, hospital notes, or even your pharmacist, physical therapist, these are medical records. And why is it important that they be accurate? Well, first of all, medical records are an important way to document what is happening during a person’s care and treatment following an accident. And if they are not accurate, it can cause a whole host of problems. For example, if you have a situation where you had a serious injury and a less serious injury–let’s say you sprained your arm, but you’ve broken your leg. In terms of your getting care for your leg, and your physician asks you, How are you feeling? Is any other part of your body feeling sore? If you answer no, you’ve given the doctor inaccurate information. If you are seeing that doctor for the leg, but you’re asked a general question or given a piece of paper to circle areas of your body where you’re hurting you should reference all areas that are hurting, even if the doctor is not interested in those areas. A lot of times we find where there can be discrepancies in medical records–if someone is going to an optometrist to get their eyeglass prescription checked and get a new pair of glasses that were destroyed in an accident. That usually results in the doctor taking a general history even though they are an optometrist or opthamologist. They take your blood pressure, they take general information, and if you were involved in an accident and you put down that you weren’t involved in an accident or you fail to even check anything about an accident, then you are not giving accurate information. So there’s two avenues of accuracy. One, you making sure you’re being accurate with the doctor. And number two, the doctor or his or her staff being accurate in what they note in terms of records.