A recent social media post by X user 'cagrown5' has brought to light a concerning incident involving a 22-year-old patient whose medical record allegedly contained a new entry of "behavioral issues" following a shoulder appointment. The patient's mother, 'cagrown5', stated that this notation contradicted a previous medical record that explicitly noted "No" behavioral issues. The patient reportedly reviewed his doctor's notes online to ascertain the date of his follow-up appointment when he discovered the new entry.
According to 'cagrown5', her son confirmed that their conversation during the appointment focused solely on his arm. The tweet also mentioned, "He was wearing his MAGA hat," implying a potential connection between the patient's political attire and the new, seemingly unprompted, medical notation. This incident raises questions about the objectivity of medical documentation and potential biases in healthcare settings.
Patients possess a legal right to access and amend their medical records under federal regulations like the Health Insurance Portability and Accountability Act (HIPAA) and the 21st Century Cures Act. These laws empower individuals to inspect their health information and request corrections if they identify inaccuracies or incompleteness. The Department of Health and Human Services (HHS) emphasizes that patients are not requesting a favor but exercising a legal right when seeking copies or amendments to their records.
Medical ethics underscore the importance of objective and accurate documentation. Research indicates that stigmatizing language and unconscious biases can inadvertently enter medical records, potentially influencing subsequent care and perpetuating health disparities. Studies have shown that negative patient descriptors can reflect and transmit bias among clinicians, affecting attitudes and treatment decisions.
Healthcare providers are advised to maintain neutrality in their notes, focusing strictly on clinical observations and patient-reported symptoms. If a patient believes their medical record contains inaccurate or biased information, they have the right to formally dispute it and request an amendment. This process typically involves submitting a written request to the healthcare provider outlining the disputed information and the reasons for the requested change.