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It’s critical for patients and families to be aware and engaged in order to receive high quality and safe care. Electronic health records, or EHRs, are a tremendous tool to use for these purposes, and you may view the data inside of them via many different forms: patient portals, computer screens during your visit, discharge papers, prescriptions, and more. Below you’ll find some suggested EHR-related actions you can take before, during, and after your medical appointment.
Before your medical appointment, you should:
Sign up for the patient portal, when available. Patient portals are your link to your own health data in the EHR and they can benefit the relationship between you and your clinicians. Ask your healthcare provider if they offer one and access your available data. This will enable you to check the data for accuracy, ask related questions, and track your health.
During your medical appointment, you should:
Verify information during your visit. During your appointment or hospital stay, pay attention to information on medical documents such as your name, date of birth, social security number, and allergies. Maintain awareness of the procedures, medications, labs, and other clinical activities you experience. Be your own advocate—if something does not seem right on your medical documents, say something to your providers. For children’s visits, make sure basic information such as their height and weight are documented correctly in the EHR. Furthermore, if that information is given in a format you don’t understand, ask how it translates into the format you prefer (e.g., asking for the weight in pounds vs. kilograms) and ask for clarification regarding your discharge paperwork, if needed.
Know that when a clinician spends time on the computer during your visit, it’s a key part of your care. Federal regulations promote clinicians using electronic systems. If you notice your doctor or nurse spending a lot of time in front of the computer, be patient and determine the best way to engage in the process. You can ask your clinicians whether they prefer to take questions while they are working on the computer or prefer to hold questions and discussion until they are done.
After your medical appointment, you should:
Review your discharge paperwork, including prescriptions and referrals. Similar to the guidance above, ensure the accuracy of your records and recommended next steps in your care. Speak up if something seems unexpected or you have questions. Use existing checklists, medication knowledge guides, and other empowered patient resources to learn about common medications that may be relevant to your health care.
Check your EHRs regularly. Just as you might review your bank or credit card statement, you should periodically request and/or access your patient record and review it for accuracy. If you detect an error, report this mistake to your healthcare provider immediately. Each provider has a different process for doing this. You should first contact your doctor directly to report the error and seek advice on how to have it fixed. In addition, the “contact” page of a provider’s website can be a good resource, and you may see contact information for related groups such as “medical records,” “patient advocacy,” “patient information,” and more. You could also call the main phone number and have the representative who answers help route a call for an EHR error.
Understand your legal rights as a patient. If you find incorrect information in your EHR, contact your provider in the ways suggested above. Also, keep in mind that more than just clinician error can lead to mistakes in your record. Sometimes the design of the EHR software can impact your provider’s interactions with your record. If you need further help navigating issues you experience, some providers may have patient advocacy groups that can help. Explore how to connect with them via the “contact” page of the website or by calling the provider’s main line.
Disclaimer: The content on this website is provided for informational purposes only and is not intended as legal or medical advice, as a substitute for the advice of a legal professional, or as a substitute for the medical advice of a physician.
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