Mistakes are a fact of life. We would all like to think we do not make them but unfortunately this is not possible. Your medical records, if you don’t know, are not immune from these mistakes. In the past, many of these records were not accessible to everyone. At the present time, with the way electronic records are being utilized, it has become quite easy for doctors or staff to “clip and paste” the same mistakes over and over again. This locks in those errors, which then seem impossible to correct. In the case of my wife, it was interesting to see this happening. Thirty years ago a physician treating her erroneously stated that she had had a hysterectomy. Although this was an error it was maintained and reproduced on almost all her records after that.
Unfortunately, medical record mistakes can follow a person’s medical record for life. I would like to think this is a minor problem but it can result in major errors in the future. The advent of electronic medical records has made this issue that much easier and more commonplace. What people might not know is that many diagnoses make it harder or more expensive to get health insurance and it is almost impossible to correct.
The increasing growth of the EMR in our future will only result in the perpetuation of these errors because right now there is no easy way for patients to fix them. This needs to change. Doctors need to stop taking the easy way out and do their own history and physical and ask the patient if the information is correct or not. Patients need access to their charts so they can help stop any errors that slip through before the cycle starts in the first place.
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As a social work discharge planner, I once had a patient with NASH. His H&P stated that he had a significant ETOH history, and 3 subsequent consults repeated this information. Having done the requisite research on NASH, I asked the patient about this; he stated that he had never used alcohol and was in process of being cleared for a liver transplant. I warned him of the information in his chart, and entered my own note (not that any MD has ever read a SW’er’s note) concerning the error. Surprisingly, I did not lose my job over this, and — more surprisingly — this occurred in the days before we had hospitalists.
Hear, hear. As a risk manager I have to do excavations on data in charts, and it’s amazing how a thought (not even a fully stated differential diagnosis) can get picked up and become a painful reality for the patient years later.
Patients don’t like it if I ask them these questions and just say something snarky like “it’s in the computer”. Later when they ask for pain medication and I tell them that several are listed in the computer, suddenly they want to go over the medications and deny everything.
Do you really think a new patient will admit to past documented problems like drug addition, alcohol abuse, etc.?