Do You Have Any Say Over What Goes in Your Medical Records?

Answers to your questions about the news.
Feb. 2 2012 4:18 PM

“The Patient Exhibits Extreme Curiosity”

Do you have any say over what goes in your medical records?

Medical records
It's your medical record. Can you control what's in it?

Medioimages/Photodisc.

The Virginia Senate passed a bill Wednesday requiring women to undergo an ultrasound before having an abortion. Women don't have to look at the ultrasound images, but patients who refuse to look must sign a statement that becomes part of their medical file. Do you have any say over what’s in your medical records?

Not really. The Health Insurance Portability and Accountability Act of 1996 gave patients the right to order copies of their medical records and enabled them to see the originals in the doctor’s office under most circumstances. It did not, however, give patients ownership of those records—your doctor or the hospital owns the file. You can try to persuade your physician not to write something in your chart, but the decision is ultimately hers, subject to legal requirements like the one included in the Virginia Senate bill. If you’re uncomfortable with information that’s already in your file, you can petition to have it amended or file a statement of disagreement, but it’s very rare (as Seinfeld’s Elaine Benes discovered) to have information stricken altogether from the record. In fact, if your doctor scribbles something in your chart that later turns out to be incorrect, she is supposed to put a single line through the error rather than blacking it out in order to preserve the record.

Patients regularly ask their doctors not to write disclosures in their records for any number of reasons. The information might be embarrassing, and they don’t want other health care workers to find out. Or there might be legal implications—perhaps the patient is planning to sue someone for an injury and doesn’t want the defendant to know about his pre-existing conditions. In some cases, legal documentation and reporting requirements prevent the doctor from granting the request. Don’t ask your doctor to keep a gunshot or knife wound quiet, for example, because they suggest criminal behavior. Indications of rape or child abuse also trigger reporting requirements. The doctor also must report certain infectious diseases, like tuberculosis, pertussis, gonorrhea, botulism, and, in some states, HIV.

There are also findings that no ethical or competent doctor would agree to omit from a medical record, even if the law allows them to do so. A cardiologist will always document severely occluded arteries, no matter what the patient says, because that information becomes critical when the patient eventually stumbles into the emergency room with chest pain. Failing to document the finding would also open the doctor to legal liability.

Aside from those legal and medico-ethical obligations, you and your doctor are free to negotiate what to include in your chart. Doctors are typically willing to omit information if they’re convinced it’s in the patient’s interest. Minors who open up about their sexual activities or want a prescription for birth control, for example, can usually keep that off the chart, since their parents have access to the medical record. Doctors have also been known to omit information, despite legal obligations, to help out people who are in a jam. For example, there have been reports of doctors failing to document progress in certain patients, so that their health insurer will continue to pay for home health care or other benefits.

Got a question about today’s news? Ask the Explainer.

Explainer thanks Arthur Caplan of the Perelman School of Medicine at the University of Pennsylvania and Leon Rodriguez of the Office for Civil Rights of the Department of Health and Human Services.

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