Are patients' electronic medical records telling the whole story?

With technologic advances have come unparalleled access to patient medical records. Since the internet has advanced, so has the flow of patients' medical records into online records and thereby, more accessible means. While this, in theory, sounds beneficial and complete, some doctors have questioned the ability of electronic medical records to tell the whole story. Are patients' medical records as complete and accurate as they should be?

The Health Insurance Portability and Accountability Act gives Pittsburgh residents the right to access and control their medical records. What is of concern, is the fact that the records may not be reflecting the entire story. Some doctors argue that the contents of electronic records may be limited by doctors' concerns about disputes with patients about what the records say, fear of malpractice litigation and questions about how much information to give certain individuals like minors and people with mental illness. These factors could have a detrimental effect on the medical records themselves, leaving them incomplete or even incorrect.

To remedy this, there has been a push to add patient-edited content. This could be especially beneficial for patients and families who believe that have suffered an incident related to medical malpractice or hospital negligence. Adding patient-created information to medical records could fill in the gaps where there is inconsistencies with medical staff records. It would also allow patients to see where certain events or instances may have stemmed from one event that could be considered for a claim of medical malpractice.

Some have argued against adding patient-created content to the medical record database because it could make the records become confusing or even inaccurate due to a patient's inexperience with the medical field.

While both sides may have a point, it is certainly in a patient's best interest to keep their own account of medical records. Whether or not these accounts appear in the official medical record, it can be helpful for the patient to cross-reference their experience with the official medical transcript. This, in turn, could determine discrepancies that may be helpful in proving a medical malpractice claim.

Source:, "Patient can't always access complete medical records, doctors say," May 24, 2016

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