Worth correcting ER documentation?
October 9, 2013 10:30 AM   Subscribe

My friend took their child to the ER for a psych evaluation. There are mistakes in the report from the hospital. Should they bother to address them?

My friend took their child to the ER a few weeks ago, because their (fairly young) child was in crisis. My friend gave a detailed history. My friend was referred to some support services. But my friend called her own pediatrician and lobbied until emergency consultation with a psychiatrist was made available and now it seems that they are working with someone very reputable and able to provide support. My friend just went to their GP (family doctor) and saw the report from the ER. It is full of a lot of mistakes and makes my friend sound like an ineffective parent. It is also missing big pieces about why they took their child to the ER and has a lot of mistakes in terms of what had transpired. I won't provide the details because I don't want to say anything that might identify the family.

Because of how the Canadian medical system works, this file will probably be in their child's medical records forever or at least until the child reaches the age of majority.

Should my friend look to correct these records? Or will anyone care about the mistakes made by an over-worked and over-tired resident who is probably still learning how to do this stuff? The family is working with a pediatric psychiatrist now for weekly appointments and feel like they are going to get proper help and support and full attention. However, the parent is concerned that these mistakes may follow the child forever, although they are unsure whether anyone will care about one ER visit many years from now.

This is in BC.
posted by Chaussette and the Pussy Cats to Health & Fitness (5 answers total) 1 user marked this as a favorite
Not a compliance professional in Canada, but do know that HIPA (n.b., not HIPAA) allows for amendment of your or your dependent's personal health information.

Cannot provide more details than that, but certainly serves as a starting point.
posted by bfranklin at 10:35 AM on October 9, 2013

Yes, your friend should do everything s/he can to correct the information. My case was very different, and it was in the U.S., but there was incorrect information in my ER initial diagnosis that caused me problems for over a year and cost me a fair amount of money and a huge amount of time and stress.

The point is that incorrect information can come back to cause all sorts of unforeseen problems. Serious, stressful, awful problems that take forever to sort out.

I went to the ER because my bad back had gone out catastrophically. I ended up having surgery. I kept getting statements from the hospital of the "This is NOT a bill" variety. Suddenly I was contacted by a collection agency because my insurance had never paid (but I had never actually received a bill).

In investigating the problem I learned that the initial diagnosis was for a facial laceration sustained in a car accident. Which never happened to me. As near as I could tell, the person who entered my info into the system when I went to the ER didn't make sure they started with a new record, and someone else's diagnosis was already in the computer. Because none of my treatment related to a facial laceration, my insurance refused to pay.

It took a shockingly long time to get that straightened out. (I guess not so shocking since I live in the U.S. where the healthcare system is filled with jaded, burned-out people who just do not give half a crap that they're screwing with the lives of real people.) It was incredibly stressful.
posted by under_petticoat_rule at 11:04 AM on October 9, 2013

Best answer: It's hard to say how the report would make your friend sound like an ineffective parent -- if it was actually critical of the parental response in some way versus omitting details of what the parent did to attempt to resolve the situation prior to the ER visit. There is a significant difference in how those things will read. Most ER reports I've seen are quite sparse, so someone looking at such a record who is told there are factual omissions is unlikely to be surprised. However, I have seen medical records that are critical of parents and this could become an issue later where a parent needs to advocate for treatment (e.g. report suggests parent exaggerating concerns).

If you actually get a complete medical file (which is not usually the case in British Columbia where more than one provider is being used, as far as I have observed - there is no big central system), you will see a variety of reports and opinions from treating physicians. Generally, opinions and reports of a specialist are going to have more weight than notes from an ER/GP visit because the person is acknowledged to be an expert and will be using specific diagnostic tools rather than general ER/GP gatekeeper tools. It is not that unusual to see two doctors who are specialists have different opinions on the same file where a diagnosis is difficult. So if your friend feels current care is competent, the file being generated with that provider is going to be the primary record anyways and the ER visit will be a footnote put in context by later reports.

Your friend should send a letter of complaint re clear errors and keep the letter if there are real concerns. Even if the medical record is not altered, the letter will provide documentary proof should the medical record ever become relevant for some reason. If it's mostly just timeline details about why the visit occurred, it's less of an issue, in my view, but if the mistakes go to symptoms/diagnosis/treatment that may be more relevant. If possible, your friend should go over the issues with someone who is a medical practitioner - some things they feel are relevant may not have a place in a medical report and what they have seen may actually be more standard then they realize.
posted by skermunkil at 11:06 AM on October 9, 2013 [1 favorite]

A letter listing the inaccuracies - not the opinions like "mother was agitated", that's not worth arguing over, but stuff like "child was cutting self for two years" when it was two months, is definitely worth correcting if that's possible.

Having their own copy of the records (not to share with the child, but as backup if she's a minor) is really helpful if they end up changing doctors, because it can take time to get the records sent over and it gets really aggravating in the middle of a crisis to have to give a history again when it has been documented.
posted by viggorlijah at 6:34 PM on October 9, 2013

Response by poster: Thanks. I'll let my friend know what you've said.
posted by Chaussette and the Pussy Cats at 2:47 PM on October 10, 2013

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