Have you ever read your medical records from your healthcare providers? I know…it is too hard and too time consuming. But if you read them you might be shocked at how inaccurate they are on some very basic and potentially life threatening ways. Examples I have seen include the wrong blood type, failing to include allergies to pretty common medications, and incorrectly labeling you a diabetic when you are not. Further complicating matters is that once erroneous or incorrect information gets into your medical records…it is repeated and copied over by all of your subsequent treating doctors.
There is an upcoming change in the law that should limit these problems. On Nov. 2, the “Information Blocking” rule of the 21st Century Cures Act, passed in 2016, will go into effect. Referred to as “Open Notes,” it states that eight types of clinical notes can’t be blocked and must be made immediately available to patients. These include:
- Consultation notes
- Discharge summary notes
- History and physical
- Imaging narratives
- Lab report narratives
- Pathology report narratives
- Procedure notes
- Progress notes