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.