Can I Ask My Doctor To Make Changes To My Chart?

This is a question I get asked often.  It is not uncommon for patients to discover an error in the chart from an incorrect diagnosis to a wrong medication or allergy.  What is in the chart defines you as a patient.  Insurance companies and medical offices only know you by what is reflected in the chart.  Therefore, it is important to attempt to make changes when inaccuracies occur.

One of my issues is, diagnoses stick like glue whether correct or not.  It is like trying to break into Fort Knox to get anything changed.  You may think what does it matter?  It does for many reasons.  First, if you try to get life insurance or long term care insurance, a misdiagnosis can get either a denial or higher monthly premium.  I don’t have asthma but occasionally use an inhaler prior to extended exercise.  I had a full work up with no tests indicating asthma.  But somebody wrote asthma and I can’t get it removed.  When I applied for long term care insurance, my premiums were higher because the chart said I had asthma.

A client of mine was diagnosed with a penicillin allergy after a visit to the ER.  She had been put on penicillin and she was having some discomfort. It was a diagnosis of exclusion.  Form that day forward, she had the alert on her chart and wristband for any hospitalizations.  At one point she was hospitalized had a rare bacterial infection and the best drug was penicillin.  Alternatives were tried but she had severe side effects.   I finally got the doctors to test her.  No allergy!  Prior attempts to get tested were met with resistance because of her age and potential side effects.  Begging didn’t work until it was a matter of life and death.

My very healthy husband, was having migraines and trouble sleeping.  The doctor suggested a sleep study.  A diagnosis of exclusion was restless leg syndrome.  He didn’t have it but it got put in his chart as a possibility.  No other problems but when he applied for an increase in life insurance, he was made to pay a higher monthly premium because of this diagnosis.

Any mental health diagnosis from anxiety to personality disorder are red flags for insurance companies and specialists. I was almost denied life insurance because someone had written the word depression in my chart.  I didn’t have depression nor was I ever diagnosed with it.  However, it had been part of a differential possibility because the physician couldn’t find an answer to my underlining and undiagnosed health problem at the time (was resolved once changed physician!)  It was not depression.

Technically, the HIPAA law gives the patient the right to change their chart.  Good luck!  It is almost impossible to get anything removed.  It isn’t that the doctors won’t try but there seems to be something in most EMR systems that reload the information.  It almost takes an act of Congress and everyone knows how hard that is!  But persistence can work.  Just know it will take time and effort.