Setting the Record Straight

No one enjoys being corrected and physicians are no different. When I speak to community groups about the patient's role in the medical visit I encourage them to get a copy of the physician note from any significant visit they might have. One example of such a visit would be a consultation with a specialist. The rational for this advice is obtaining the note allows the patient a chance to verify that the facts presented in the history are correct. Oral communication is especially prone to errors- nervous patients may mis-speak or be misunderstood. Tired or distracted physicians might miss unique details of the complaint or prioritize the symptoms differently from the patient. The assessment and plan that the patient "hears" might not be what the physician thought they said. Reviewing the note allows the patient to clear up misunderstandings, if they exist. This needs to be done in a timely fashion because what's recorded in the record seems to become "gospel" and could interfere with future evaluations if the facts are wrong.
Patients often find that receiving copies of visit notes can be difficult. I'm not sure why this should be the case as the record belongs to them. But the truly tricky part in this process for patients is getting the record amended/changed if it's incorrect. Calling the physician to inform them of discrepancies may be the easiest route but it doesn't guarantee that the record will be amended. Patients can write a letter which includes the changes they want to make to the history but that can get buried in the correspondence section of the chart, doing little to reflect the true history as documented in the physician's notes. I think the best approach is to schedule a follow up visit to review the history and have the corrected version entered in the note from that visit. On the physician side of things, we need to be open to the idea that we may make mistakes in recording the history. We need to understand that patients who request such changes are not threatening us but simply trying to fulfill their role in the relationship. An honest exchange such as this will strengthen the trust between the patient and physician and will lead to better care. Mistakes in history gathering/recording happen. They should not be compounded by an unwillingness to acknowledge and correct them.