Communication Errors: How To Prevent

First, read your own medical records. Especially you should ask for a prompt copy of any recently done test on you. Never assume that “no news is good news.”

Here’s what I wrote in our firm’s patient safety newsletter on why I made “getting and reading your own medical records” Step One in my nine-step system for better medical care. (More on this in my book: The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst)

Reading your own medical records is an essential first step to becoming a proactive, informed patient. It accomplishes several important goals all at once.

• You learn a lot about your doctor. How organized are his or her records? How complete and accurate are the records in recording what you said in the visits? You might want to consider getting another doctor if the doctor doesn’t score well on this simple test.
• You become literate about your own body and about the lingo your doctors use.
• You remind yourself of concerns your doctors may have about you that you would rather not think about.
• You can fix mistakes. Do your records say something about you that’s just plain wrong? Or do they leave out something important, like an allergy to penicillin or some other common drug? This gives you a chance to correct errors before something bad happens.
• You can prevent potentially enormous breakdowns in communication. People find abnormal test results in their own records more often than you would think – but people usually don’t look until it’s too late. Never assume no news is good news! There are too many test results getting filed into medical records and too many opportunities for communication breakdowns.

One special focus should be on obtaining a copy of every X-ray study, lab result, and specialist’s report. The easiest way is to start asking for these routinely, up front, when you’re about to have the test done. But if you’ve got any kind of complex medical history, go ahead and ask your primary doctor’s office for a copy of your entire chart.

How do you do it?

Just ask. Put it in writing. You have a legal right to your records in all 50 states and the District of Columbia. Remember, it’s your body, and you can save a life, maybe your own, by reading your own records.

By the way, people often are told at laboratories that they will only release results to the requesting doctor. That may be their policy, but it is not the law. You have a right to these results and should be persistent.