Correcting medical records

February 17, 2008 12:29 PM

Can incorrect and speculative family history be corrected on my medical records?

My medical records show a family history of depression. Can I have this corrected?

I was diagnosed with pure O OCD during the last month of my first pregnancy, but I never became depressed. I experienced the symptoms for about 4-6 months after the birth of my first child. When I was referred to reproductive psychiatry, my family doctor asked if my mom or grandma had suffered from depression. I said, "Yeah, probably." When I saw the reproductive psychiatrist, she asked if my mom or grandma had suffered from depression. I said, "Yeah, I think so."

About a year later, I was injured in a car accident that the other driver took 100% fault for. I got a lawyer. My lawyer told me I needed to have my med records released, but that he would black out anything personal. I explained that I'd had this perinatal depression -- not that I had ever been depressed, but that I'd had the Pure O OCD. He said it wouldn't be a problem and that he could black anything out and that he didn't necessarily even need to release it all. When I told my GP, she was very concerned about my records getting into the hands of anyone other the medical profession. But she agreed that my credibility in the personal injury case depended on transparency. So we sent the records to the lawyer.

My lawyer now has them and says that the perinatal mental health issues cannot be blacked out and, further to that, he must release the records. But, further complicating things is the family history of depression. I never knew that I was being asked if my family members had been diagnosed with depression. In fact, it was my own speculation and it was based on my grandmother feeling very sad after moving here as a war bride and finding herself isolated and living in a very, very poor rural area with a husband who had (lovingly) misled her about his financial profile. Meanwhile, my mom had been kinda down when I went off to college and she lost her job at the same time. Even though both of them went to their doctors and talked about how they were feeling, they were never diagnosed with depression. And it was all situational.

So, I was incorrect about the family history of depression, which I didn't even realize was being recorded as family history. (And I didn't know it was being recorded as family history.) Is there anything I can do about this now?

(Sorry for the rambling post -- I'm trying to provide info to help with the anonymous question, not fixate on the situation!)

Thanks in advance.

posted by anonymous to health & fitness (4 answers total)

There is no way that the recording physician can retroactively alter the medical record he created, even if it's wrong. To do so would break all kinds of laws. He can make a new entry as of today, documenting the error and correcting it, if you can convince him it's worth his trouble to do so.
posted by ikkyu2 at 1:28 PM on February 17, 2008

In California, you have the right to inspect your medical records. If you find any inaccuracies, you should write a statement to that effect and have it added. It can be a very simple statement along the lines of "my mother and grandmother were nevr diagnosed with depression by a medical professional, and when I was asked if they had depression, it was purely speculative on my part" or something like that. I have no idea what the law is in other states, but with privacy laws being what they are, I imagine that you have similar rights to your records in other states as well.
posted by dogmom at 2:00 PM on February 17, 2008

You cannot alter an old medical record. Maybe try explaining the error to your doctor and asking him to write something like "patient's family hx of depression seen in note dated xx/xx/xxxx is incorrect/uncertain."
posted by ruwan at 2:51 PM on February 17, 2008

You seem to think that a family history of depression requires a diagnosis to have been made for your family members. This is just not so. Even today, many people with raging mental illnesses are never diagnosed as such. When we're talking about decades past, it has to be single digit percentages of women with non-decompensated clinical depression who ever got diagnoses, to say the least of treatment.

A bad medical record can be mitigated. If a practitioner was at fault, you might be able to get the court to let your lawyer redact ("black out") out the bad material before handing it over. Even without practitioner fault, you might be able to get the family history held out of evidence as prejudicial unless the other side can corroborate it with some other evidence. You can also just testify or bring in other evidence on the subject yourself, which your expert can use to support a conclusion that whatever blues your mom and grandma may have had were sub-clinical.
posted by MattD at 5:40 PM on February 17, 2008