Accuracy of Medical Records

Accuracy of Medical Records

Utah workers compensation benefits largely depend on the accuracy of medical records.  Medical records are the primary evidence–along with the injured worker’s testimony–about the industrial injury.  Hence, one of the first things we assess is whether there is medical evidence to support the claim.

Mistakes in Medical Records

Occasionally the medical records contain mistakes, i.e., referring to a female patient as “him” or mixing up “right leg” with “left leg.”  Sometimes errors are more significant, such as saying an injury is not industrial because the doctor, for example, does not understand that in Utah cumulative trauma at work constitutes an industrial accident.

Federal law allows patients to request changes or corrections to their medical records.  But changes are not the best.  We want to avoid the need for changes.

Best Practices

The best practice is for the patient to (1) ask the medical assistant during the initial intake to please ensure the medical record address all complaints.  Typically, it is the medical assistant–who may be a recent high school graduate with limited knowledge of medical law–that creates your medical record.  So, if you complain to the doctor about something but you do not tell the medical assistant, there is a chance your complaint will

accuracy of medical records
The medical assistant is very important!

not be included in the medical record.  So, #1 task is be very clear and perhaps a bit redundant with the medical assistant that you got hurt at work.

The next best practice is for the injured worker to record the intake exam at the doctor’s office.  Then, get a copy of the medical record as soon as it becomes available and ensure it is accurate.  If not, use your recording if needed to get the medical assistant to correct the record.  Be kind and gentle and the medical folks will likely be happy to fix their mistake.

Ask an Attorney!

At Tim Daniels Law Services, we regularly counsel with injured workers about their questions about industrial accidents, insurance medical exams, workers comp adjusters and Utah workers comp benefits.  On Facebook or you may reach us by calling or texting Attorney Daniels’ cell at (435) 592-1235 (for free, of course).