When your physician sends you for a test, how many times do you receive a copy of that test? Shouldn’t you know what is in those records? Is it possible that given the busy nature of your physician’s practice that a lab sent to him or consultant’s report may not be read fully and completely? Is it possible that something will be missed?
Yes it is possible, here is an example:
Jeremy (not his real name) should have been told by his dermatologist that the skin biopsy taken from his face showed a squamous cell carcinoma. Instead, his dermatologist treated his skin lesion as if it were a basal cell carcinoma because that’s what it looked like. When the dermatologist received the pathology report, received many days after taking the specimen and providing treatment for basal cell carcinoma, he filed it away without ever having read it.
I never met Jeremy. He died due to his untreated squamous cell carcinoma. But I represented his family in the wrongful death claim brought against the dermatologist.
Jeremy had done nothing wrong. It was the dermatologist’s duty to read, understand and react to the pathology report. But Jeremy’s life was lost because his dermatologist did not read a pathology report. Jeremy may still be with his family had he asked to see that pathology report himself and not relied upon the dermatologist to tell him if the result was bad.
How many of you reading this know what is in your own medical records?
Under Pennsylvania law, your medical provider is the legal custodian of your medical record but you have the right to see, to obtain copies of and to direct transfer of your medical records to another healthcare provider. The medical provider has 30 days within receipt of your written request for your records to provide them. Providers may charge reasonable copying fees and also charge for shipping and postage.
In addition, you can request to have information added to your medical record in order to make it more complete or more accurate. Your provider must consider your request and respond to it within thirty (30) days of receipt of your written request.
However, getting your records is only the first step. You must read them and you must understand them.
A website called “Lab Tests on Line” (http://www.labtestsonline.org//) allows you to look up thousands of clinical lab tests and found out what they mean and how to interpret the results. You can also utilize the Internet to translate the acronyms that many medical providers use to describe information regarding your care.
Many of us are hesitant to ask for our medical records. Will the doctor think we are questioning his authority? Will the doctor think we are considering suing him? Will the doctor think I don’t trust him? Won’t the doctor tell me if any of these tests and consults that she is requesting show something to be concerned about? Isn’t no news good news? These are all common questions, concerns and fears that affect our ability to be our own best advocates.
To receive the best possible care you must overcome these concerns. By your requesting a copy of your records and making it known to your physician that you wish to receive a copy of every diagnostic study, lab test and/or consult report, you are sending a message to your doctor that you are a conscientious patient vitally interested in your own care. This will have the secondary effect of making your doctor know that someone is watching her and will cause her to step up her game.
As always, should you have any questions about how to obtain your records or, how to read them once you obtain them, please do not hesitate to contact me.
Tony Baratta is a trial attorney in Huntingdon Valley, PA who represents clients who have been seriously injured including due to medical mistakes. Tony is the founding partner of Baratta, Russell, & Baratta and on the board for the Philadelphia VIP. Tony is a Nationally Certified Civil Trial Advocate, AV Rated Preeminent by Martindale-Hubbel and a member of the Pennsylvania Brain Injury Association (BPIA). He is also a member of the Million Dollar Advocates Forum for trial attorneys and voted one of Philadelphia’s Super Lawyers 2008-2015.
