Once you’ve got your health record, review it to make sure that all of your health information is complete, correct, and up-to-date.
In this section:
Once you’ve got your health record (also known as a medical record), review it to make sure that all of your health information is complete, correct, and up-to-date. This is important because you may have forgotten to tell your doctor something or they may have forgotten to write it down. The folks in your provider’s office are busy people, who make mistakes just like everyone else. Some examples of common errors:
- You may have forgotten to tell your doctor about something — like a new medication or allergy
- Your doctor might have misunderstood, incorrectly noted, or left out something — like information about your health history or your symptoms or the date of your appointment
- Your doctor might have ordered a test you’ve already had — or charged you for a test you didn’t have
If you don’t review your record, you won’t know these mistakes have been made, and they could impact your future health and treatment. Explore these tips on what kind of mistakes to look for — and what to do if you find one!
It’s important to check it!
Nearly 1 in 10 people who check their online health record ask to have a mistake corrected.
Source: ONC Data Brief 40 [PDF - 1.7 MB]
What kind of mistakes am I looking for?
You’re looking for mistakes or out-of-date information that will have an effect on how your provider diagnoses and treats you, whether your provider can contact you, and how you’ll be billed. You can let typos go, but if a mistake can affect your health, it should be fixed.
Check your personal information:
- Name, address, and phone number
- Health insurance plan provider
- Identification numbers, like your patient identification number or social security number
- Emergency contact names, addresses, and phone numbers
Check your health information, including:
- Doctor’s appointment notes
- Health or medical history
Check your medical bills:
Make sure you’re only being billed for services you’ve received. You can do this by comparing the information in your health record with:
- The reports your health insurance plan sends you
- The bills from your doctor or other health care providers
Frequently Asked Question
Some of my older records are missing — can I get them?
Yes, if they still exist. State laws determine how long a provider must keep your health records — and it varies from state to state. Some providers archive (store) older records offsite. If you haven’t been to your provider in more than 5 years, your records may be archived — but you still have the right to get a copy.
What do I do if something is incorrect or missing?
Under HIPAA, if you think there’s a mistake in your health record, you have a right to ask your provider to fix it.
If you want to have a mistake fixed, here are the steps to follow:
Step 1: Contact your provider
Contact your provider’s office and find out what their process is for making a change to your health record. They may ask you to write a letter or fill out a form. If they have a form, ask them to email, fax, or mail a copy to you.
For more information about how to contact your provider, see How do I get started?
Step 2: Write down what you want fixed
If your provider has a form, and you want to fix a simple mistake: Fill out the form and attach a copy of the record page where you found the mistake to help them find it.
If your provider doesn’t have a form or it’s a more complex mistake, you may want to write a letter describing the correction. Make sure you include:
- Your full name, address, phone number
- Your doctor, nurse, or provider’s full name and address
- Date of service
- A short, specific, and clear explanation of what needs to be fixed and why
- A copy of the record page where you found the mistake
- Your signature
Step 3: Make a copy of your request
Make a complete copy of everything you’re sending to your provider for your own records.
Step 4: Send your request
Depending on your provider’s processes, you can deliver your request by:
- Secure email through your patient portal
- Non-secure email (your personal email)
- Mail (standard postal service)
- In person
Note: If you want to send your request by email (secure or non-secure) you’ll need to attach digital copies (PDF files) of the record page where you found the mistake and the request form. Remember, using secure email or a patient portal helps protect your privacy and personal information.
Find out who needs to fix the mistake
Make sure you address your request to the specific doctor, or other provider, who made the mistake. It will be their responsibility to fix it. Note: Your doctor or provider may have retired or changed practices. If this is the case, the clinic, office, or hospital can tell you who should receive your request.
Frequently Asked Question
I care for my child, a family member, or another adult — can I ask to fix something in their health record?
Yes, if you’re that person’s personal representative the process is the same as fixing a mistake in your own record. Under HIPAA, a person who can legally make medical decisions for someone else is called a personal representative. Providers are not required to respond to requests from caregivers who are not personal representatives. If the person is someone other than your child, the provider may ask to see a copy of your power of attorney (legal paperwork) before responding to your request. Get more information on personal representatives.
What happens after I request a correction?
Your provider has 60 days to respond to your request, unless they ask for an extension (extra time). Here’s what you can expect:
If your provider agrees there’s a mistake in your health record, they’ll update your record and send you a notice — either in your patient portal or via email or mail — that they’ve taken care of it.
If your provider does not agree with you, they’ll send you a denial notice that should include:
- The reason they’re not going to fix the mistake. For example, they might say they believe your health record is correct and complete.
- Information about how to reply to their decision
What do I do if my provider doesn’t agree with my request?
If your provider does not agree that there is a mistake in your health record, you can:
- Send them a formal letter in reply to their decision, stating clearly why you disagree. Their denial notice should include instructions on how to do that. If not, call their office. This response will be attached to your health record.
- If you don’t want to reply to the denial notice, you can ask your provider to attach a copy of your original request and the denial notice to the affected page(s) of your health record.
- File a complaint with the Department of Health and Human Services. Get more information on filing a complaint at HHS.gov.
Activity: Medical Jargon Mastery
How many of these medical words and abbreviations do you know? Click on the words to reveal their definitions.
BID stands for “Bis in Die,” which is Latin for twice a day. Your doctor or nurse would use this abbreviation when they prescribe a medication.
Fatigue is when you become extremely tired in your mind or in your body.
Hypertension is when you have high blood pressure.
Anemia is when your blood is low in red blood cells.
CBC stands for complete blood count, a blood test that measures the number of different types of blood cells, like red and white.
HA stands for headache.
Osteoporosis is when your bones lose density (thickness) and become brittle.
N/V stands for nausea (feeling sick to your stomach) or vomiting.
The thyroid gland makes and stores hormones that regulate things like your heart rate, temperature, and blood pressure.
LBP stands for lower back pain.
Medical words and abbreviations can be confusing for us all. If you don’t know what something means, ask your doctor. You can also look up abbreviations online at Medlineplus.gov.