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We talk to clients all the time about what is in their medical records. It is not surprising to find people strongly disagreeing with what is or having a different memory of what the doctor said. They aren't always upset about it, but often will say that they wish the doctor had explained it better or been clearer about their options.

In many cases, it's probably the amount of time that is spent making sure that people understand what happens in each visit. It means that there really needs to be communication and that the notes need to reflect what happened.

USA Today carried a story about a study that looked at the affect of people reading their own records:

Researchers found that more than 90% of the patients surveyed wanted to see the notes, saying such knowledge would help them take more control of their health, would help them remember to take their medicine on schedule and would help them to be more responsible about their health. A smaller subset, 22%, said they would use the information in the notes to talk with other people, including other doctors, to help manage care.

Doctors were somewhat less enthusiastic, though their responses varied depending on whether the doctors were taking part in the yearlong study or not. Overall, doctors felt the notes could help patients communicate better with physicians and that patients would be better educated about their health… but also felt the information was more likely to worry patients or to elicit more questions from patients in between visits.

Often the concern we have is when records contain inaccurate information, which, while not disclosed by the doctors, has to be another reason for their lack of enthusiasm. This alone is a good enough reason that people should take the time to review their records as they are getting care. The real issue is making sure that there is clear and accurate documentation of care.

I do understand that there can be concerns about people obsessing or being hurt by what is said, but again, it seems that communication can deal with many of those issues. It will require people to take more interest and time in reviewing what is documented, but it will also up their participation in the whole process.

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