computer keyboard

There was a time when doctors had lots of time to listen. They weren’t as rushed as they are today. They asked lots of questions, wrote notes in your paper chart and then took time after the interaction to finalize the diagnosis and the plan of treatment. Today most doctors type into your electronic medical record on their computer.

How Accurate is the Electronic Medical Record?

Have you checked your electronic medical record recently? You might be surprised at what you find there. Of course the chances are pretty good that you will only see the tip of the iceberg. That’s because the “OpenNote” system that provides you the doctor’s clinic notes are rarely divulged. Learn more about accessing OpenNotes in our recent article at this link.

New Insights on Electronic Medical Records:

A study conducted with 162 patients in an eye clinic found significant discrepancies between symptoms patients reported on a paper form at check-in and what was found in the electronic medical record after the visit. About a third of the time, information on whether the person suffered blurry vision did not agree between the two.

In 60 cases, blurry vision was noted in both records, but in 25 cases patients had written that they had blurry vision and the electronic record did not note it. There were also differences in reports of pain, light sensitivity, glare, itching, redness and a gritty sensation. These were noted on the paper questionnaires more often than they were included in the electronic health record.

What’s the Big Deal?

Clinicians rely on the electronic medical record to diagnose patient problems and determine the best treatment, so when they are inaccurate, patient care may be delayed or derailed. When there are missing data all kinds of harms can occur. Lab results that are not entered accurately can delay crucial treatment.

We encourage you to access your electronic medical record and verify that all the information is accurate. If there are things that are missing or outright errors, make sure they are corrected.

How Can You Get Your Medical Records?

 

JAMA Ophthalmology, online Jan. 26, 2017

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  1. Susan
    NC
    Reply

    Several of my local doctors have now merged with a popular university, which is also now “in charge” of my local hospital. When the merger happened, they must have had problems starting their new data operations and had to go back further in the records to make the merge happen. I know this because all of a sudden my medical records were reflecting ancient information about drugs I was taking, my condition and doctors I was seeing.

    This was very alarming to me! I asked several times that my records be corrected. No one seemed to think it was a big deal. I DO! I have several major health issues, including cancer. What if I were to show up at the ER unconscious and not able to fend for myself! Going to the computer data systems they are now using is a bad thing…Plus, I want my doctor to look at me and not a computer screen!

  2. Cindy M. B.
    Seattle, WA
    Reply

    I agree: It’s vital to check one’s official medical records. ESPECIALLY if it’s, say, a teaching hospital or other facility where various people are able to put notes in your chart. You should ESPECIALLY be careful not to disclose something kinda “iffy” in a moment of weakness or, ah, black humor (“Yesterday, I was so stressed out by “x” that I had 4 glasses of wine.” “The traffic was horrible coming here. I hate traffic; it makes me CRAAAZY!”) etc.

    Because the budding young med students, so eager to make a name for themselves, decide to enter their own designations in your problem list: “Alcoholic!” or: “Anxiety disorder!” They don’t ask for clarification; they certainly don’t ask for permission; they just put the thing in to demonstrate how creative and astute they are. Maybe you notice it 6 months later and say “WHAAAAAT?!” And by then, who knows how many people have read your chart and formed opinions about you! I have learned my lesson. Now I say NOTHING “off the cuff” in my conversations with doctors, and I always check my records afterwards.

  3. Shirley
    Florida
    Reply

    This article hit home as I’ve been upset by reading medical report that was written about me,which was totally false. It stated that I was non-compliant in using my meds. which is far from what was told to new tech,which typed in the information. I’m one of the patients that has Alere monitor system,it was recalled,but you are to use the system until transition to another form of blood monitoring for clots. I was yelled at from Tech,who stated there was not any calls from the company depicting my results,why?

    I explained that the Manufacturer, Alere was recalled, and she insisted that I was wrong, as other people who had the unit are still being monitored. The distributor,known as Remote Cardiac Services,wanted to replace with another digital machine,just not to lose money each month from Medicare. I refused to accept any machine,opted to finish the strips provided,then look for lab test,as they lie to patients making them test weekly to benefit their bottom line, when two Dr.’s said only once a month is used, even in the lab setting.

    Calls from me to the cheats were not answered,they changed their name and refused to take old pin numbers to report my blood numbers. Now I’m taking the warfarin still,as I have strips still, and my report reads that I’m not compliant, which is far from the situation,as I’ve been a healthcare worker over 40 yrs,and capable of knowing what I’m doing. This has been discussed by others on internet,so forcing weekly testing for higher fee from Medicare is fraud. This Dr’s report is not only wrong,but unfair, and will hurt my next relationship with another Cardiologist, as they are dropping my insurance.

  4. NJ
    GA
    Reply

    Just last week I received new glasses and could see nothing because the refraction results had been entered incorrectly into the computer and then printed out as my prescription. In December, after seeing a physician, I noted that they had my weight as 80 pounds more than I weighed when the medical assistant had checked me in. Furthermore, I have had my records hacked twice in physician’s offices. Thanks for the great advice. We certainly do need to be careful.

  5. Emily P
    Reply

    Great Article. I think you should post on ProPublica, Medical Error Transparency Plan, Mothers Against Medical Error and Diagnostic Errors Facebook groups. BEt you would help others and get more members.

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