The Personal Medical Record Audit

You check your credit report. Check your chart, too.

Your medical record follows you for life.

It can influence the care you receive, the medications and allergies clinicians see, how your health history is understood, and—in some circumstances—information used in insurance and claims decisions.

But when was the last time you actually checked it?

The Personal Medical Record Audit is a 143-page consumer guide and annual workbook that shows you, step by step, how to review your own medical records for inaccurate, outdated, missing, duplicated, or potentially wrong-patient information—and what to do when you find something that doesn't look right.

No medical background required. No healthcare IT knowledge required. Everything is explained in plain English.

Learn What Your Medical Record Actually Says About You

Your patient portal is useful—but it isn't necessarily your complete medical record.

This guide shows you where your health information can live, how it moves between healthcare organizations, and how to systematically review the information that matters most.

You'll learn how to check:

• diagnoses and your problem list;

• medications, allergies, and immunizations;

• laboratory and imaging results;

• procedures and surgeries;

• clinical notes and medical history;

• demographics, insurance, and administrative information;

• information that may be outdated, duplicated, or copied forward;

• entries that may belong to another patient; and

• records held outside the portal, including health information exchanges, registries, and certain insurance-related databases.

You'll also learn how to read a clinical note—including the difference between what you reported, what a clinician observed, and the clinician's professional assessment—so you can distinguish a genuine factual discrepancy from something that simply looks unfamiliar.

Find Something Wrong? You'll Know What to Do Next.

Finding a questionable entry is only the beginning.

The guide walks you through an Eight-Step Correction Framework for documenting the issue, finding its source, requesting the appropriate records, contacting the right organization, requesting an amendment when appropriate, tracking the response, and verifying what ultimately changed.

It also explains your medical-record rights in understandable language, including HIPAA access and amendment rights, information blocking, designated record sets, health information exchanges, CommonWell, Carequality, TEFCA, registries, MIB and prescription-history reports.

And because correcting information at one healthcare organization doesn't necessarily correct copies that have already traveled elsewhere, you'll learn how to follow the information downstream.

More Than a Guide—It's an Annual System

The goal isn't to make you obsess over your medical record.

It's to make checking it routine.

The Annual Chart Check gives you a repeatable process you can perform once a year, much like reviewing your credit report.

The package includes 7 reusable worksheets to help you inventory your records, document questionable entries, track requests and amendments, follow up, and create an annual audit summary.

And when it's time to actually contact someone, you won't have to wonder what to say.

Includes 32 Ready-to-Use Letters, Messages & Scripts

You'll receive practical templates for situations including:

requesting your complete medical record • requesting a missing record • questioning an unfamiliar diagnosis • updating medication information • requesting an amendment • responding to a denied amendment • asking that corrected information be sent downstream • reporting possible wrong-patient information • following up on unanswered requests • and more.

The templates are also provided in a separate editable Word document, so you can customize them without copying and reformatting text from the guide.

Created by Someone Who Knows the Medical Record From Both Sides of the Screen

Shane Huey, MS, MBA, RN, LNC has been a Registered Nurse for 14 years and has spent more than 11 years building, maintaining, and working with electronic health record systems.

His work sits at the intersection of clinical care, healthcare IT, electronic documentation, and regulatory requirements.

As a Legal Nurse Consultant and Clinical Investigator, he also examines medical records critically—tracing where information came from, comparing conflicting documentation, identifying what may be missing, distinguishing repeated information from independent evidence, and determining what the record actually supports.

The Personal Medical Record Audit brings that experience to consumers in plain English.

What You Receive

The Personal Medical Record Audit — PDF
143-page consumer guide and annual workbook
16 chapters
7 reusable worksheets
Plain-language HIPAA and patient-rights reference
Medical terminology and abbreviation references
Healthcare and regulatory resource directory
32 letters, portal messages, and phone scripts

Editable Letters, Messages & Scripts — Word
All 32 templates in an editable format for easy customization.

$39

Your medical record tells your health story.

Make sure it's telling the right one.