Medical errors and medical records, proposal March 2007

Proposal for authorisation of medical records by the patient.


As acknowledged by Prof. Legemaate of the Royal Dutch Medical Association (KNMG) in his augural speech May 2006, Free University Amsterdam, physicians generally do not inform their patients about the occurrence of a medical error.
This implies that the medical records are often not complete or not completely correct, in order to conceal the medical error as much as possible.
For the patient/victim of the medical error it will thus be very difficult to prove the error.

Physicians also register-unjustly- often in the records that they informed the patient extensively or that the patient refused or requested certain examinations. Sometimes we even find derogatory remarks about the patient.

After the occurrence of a medical error, the patient/family members should request a copy of their medical records as well as the nurses records as soon as possible.

In order to avoid any misunderstandings or deliberate changes we plead to install a standard procedure for medical records:
-at the end of each consultation the physicians hands a copy of the report of the consultation in order to enable the patient to check and correct it.
-the report of a medical consultation is only valid and has legal status when the patient has put his signature of approval under it.
-likewise for all medical records by nurses and other healthcare professionals.
In addition: no correspondence without authorization( signature) of the patient.
Too often letters which contain incorrect information have been sent by physicians, assuming permission by the patient. No permission can be assumed automatically. No area of activities in our society permits professionals to write letters without the consent of the individuals involved. The privileges which the medical profession has assigned to itself are incorrect and have been unjustly obtained. Transparency requests prior consultation and authorization of/by the involved patient. All letters which a medical professional sends should be authorized by a signature of the involved patient.