Engaging Patients in Their Own Record Accuracy

Introduction: Patients as Partners in Documentation

We often think of the medical record as a tool for providers, payers, and auditors—but it’s also the patient’s record.

When patients are actively involved in reviewing and correcting their information, it improves safety, accuracy, and trust.

A patient who helps keep their record accurate is an asset to the entire care team.

Step 1: Why Patient Engagement Matters for Accuracy

• Error Prevention – Patients can spot outdated medications, incorrect allergies, or wrong procedure dates.
  
• Improved Safety – Accurate records reduce medication errors and diagnostic mistakes.
  
• Better Continuity of Care – Correct information supports smoother handoffs between providers.
  
• Transparency – Patients feel more confident when they see what’s recorded about them.
  

Step 2: Common Errors Patients Can Catch

• Misspelled names or demographic mistakes.
  
• Incorrect medication lists or dosages.
  
• Outdated diagnoses that no longer apply.
  
• Missing test results or hospital visits.
  
• Incorrect family or surgical histories.
  

Step 3: How to Encourage Patient Review

1. Leverage Patient Portals – Give patients easy online access to their records.
   
2. Provide Visit Summaries – Hand them a printed or digital summary at each visit for review.
   
3. Ask Directly – During the encounter, ask if any information in the chart is incorrect or missing.
   
4. Create a Simple Correction Process – Make it easy for patients to submit updates or corrections.
   

Step 4: Integrating into the Workflow

• Train staff to review demographics, medications, and allergies at every visit.
  
• Encourage patients to bring medication lists or bottles to appointments.
  
• Use intake forms to verify health history before entering it into the EHR.
  

Step 5: Compliance and Documentation

• Document patient-reported corrections in the chart.
  
• If you disagree with a patient’s requested change, note the reason.
  
• Ensure HIPAA compliance when sharing or updating information.
  

Step 6: Benefits Beyond Accuracy

• Increased Patient Satisfaction – Patients feel heard and valued.
  
• Reduced Liability – Correct records strengthen your defense in case of a dispute.
  
• Fewer Administrative Headaches – Up-to-date records prevent unnecessary follow-ups and miscommunications.
  

Common Mistakes to Avoid

• Ignoring patient feedback because “it’s probably not important.”
  
• Making changes without verifying with the clinical team.
  
• Giving patients access but no education on how to use it.
  
• Treating record accuracy as a one-time task instead of an ongoing process.
  

Final Thoughts: Shared Responsibility Improves Care

Accurate medical records are the foundation of safe, effective care.

When patients participate in keeping those records correct, it’s a win for both the clinical team and the individual’s health outcomes.

Patients aren’t just the subject of the record—they can be its most valuable editor.

About the Author

Douglas J. Jorgensen, DO, CPC, FAAO, FACOFP

Dr. Doug is a physician, consultant, and national educator on medical documentation accuracy, patient engagement, and compliance strategy. He helps healthcare organizations develop systems that make patients active partners in their own medical records.