Sunday, May 4, 2014

Why Getting Your Records and Understanding Them Is So Important

If you have been following my Diverticulitis journey through healthcare, I have an important message. Please be sure that you get your medical records and read them. Nobody is more likely to catch errors than you or your family. It is your body, your history, and it is much more likely that something abnormal will jump out at you. This is one of the main reasons we started CareSync. it was so difficult for me to get all of Morgan's medical information and then to have access to share it in a meaningful way was very time consuming, costly, and difficult. A binder was the most effective thing I found before CareSync, but that is extremely inefficient.

So, my CT report had a significant error in it. As you know, I was hospitalized for 5 days for diverticulitis, but this is what the report said.

"CT scan does not show mild focal wall thickening and surrounding mesenteric edematous changes within the very proximal rectosigmoid consistent with acute diverticulitis."

It goes on to say that everything else was normal except small kidney stones in my right kidney (shocker. I seem to always have at least one kidney stone).

Does anyone see the word that was a typo? I will give you a hint. It is not a medical word. Still don't see it? It is the word NOT. It says it does NOT show changes consistent with acute diverticulitis. I contacted the hospital when I saw the report thanks to Dr. Mihale and CareSync Medical Group.

I was going through my mail from yesterday, and I got a letter from my primary care doctor. It said,

"We received your CT scan of your abdomen and pelvis from Florida Hospital Wesley Chapel the other day, and Dr. Yousef found some kidney stones. He would like you to come in for follow-up. Please call us to schedule an appointment."

Now, I was lucky in this case that I was actually admitted to the hospital and got a lot more information over the course of 5 days, but imagine that I had this test and went home from the ER. My primary care doctor would never have even questioned the CT report. Imagine looking at that report a year from now. Would anyone remember or believe that it was an error at that time?

At CareSync, we have found that about 34%of patients have reported finding errors in their medical record when CareSync gets them and puts them into a format that is easy to read.  I have found that in the QA process for CareSync, it is MUCH easier for me to spot an error in a member of my family quickly than it is for QA to check data back and forth on fake patients we use for testing. I have realized through this process that doctors are looking at data like our QA look at our fake patients. The data requires a lot of study to catch errors. It is also kind of like when you write a paper and don't see the errors because you are so familiar with what you wrote. As a patient, we can be the best editors and error catchers that exist.

Please be sure to get your medical records. Of course, I highly recommend letting CareSync do the work for you, but if you don't want to use CareSync, then go to your doctor or hospital and request the records yourself. Read them. Look for things that might be wrong. It really is important.


  1. So, what's the deal?? Was it a typo?? Or did the doctor simply make a (big) mistake??

    I recently realized that a 2007 radiology report about my hip was flat-out WRONG when it said "patient is status post hip replacement," in other words that I'd had a hip replacement. I did have a rod put in my thigh, and a pin into my pelvis, but my hip joint was not replaced. WRONG.

    And nobody's interested in fixing it!

    (Not to mention the one that identified me as a 53 year old woman.) (I'm not exaggerating.) (And this is all at Beth Israel Deaconess, a big Boston hospital.)

    So I'm really curious - where did the mistake happen? What did the doc do wrong?

  2. Sorry that I wasn't clear! The NOT word was not supposed to be there. It was diverticulitis but there was a typo in the sentence. It confused my primary care doctor who then read the rest of the report trying to figure out what was happening.

    We have also found many other errors in other family member's records including diagnoses that weren't accurate (Diabetes and Panniculitis), the wrong leg mentioning a biopsy site - imagine future rechecks happening on the wrong leg when you no longer remember which leg it was, and more. These errors easily spread like this one going from the hospital to my GI doc and my primary care.

  3. I had the same thing happen with my daughter's MRI report last year. Same exact typo, only the NOT was missing! She did NOT have any new areas of inflammation. I made them make an addendum to the report, but the actual, original wording remained. Crazy.