Three ways to improve the accuracy and safety of your medical records

 

2017 study: There's a big gap gap between what patients tell their doctors and nurses and what is written down in the chart

 
March 24, 2017

A 2017 study has confirmed what I already knew from years of practice as a Texas medical malpractice attorney. A report in the journal JAMA Ophthalmology shows that the symptom information given by patients did not match what doctors wrote in the medical records for the following:

          Glare: 48 percent of the time

          Pain: 27 percent of the time

          Redness: 25 percent of the time

This is downright scary. How can doctors and nurses provide the correct treatment if they do not even have correct information about your symptoms and what medical problem brought you to them in the first place?

This is particularly dangerous with the increasing use of electronic medical records. Once fake information gets into your chart, it gets cut and pasted or even automatically populated in future medical records. In a hospital admission, that means that if an emergency room doctor or nurse records incorrect information, then doctors and specialists who are treating you down the line will likely be repeating and relying on bad facts.

A Reuters article quoted Dr. Christina Weng of Baylor College of Medicine, in Houston, as saying, “Data accuracy in patient medical records is absolutely critical.” According to Reuters, Dr. Weng went on to say, “Any inaccuracies in the record could potentially threaten or delay patient care.”

In other words, bad information can lead to wrong treatments and can lead to dangerous consequences to patients.

Wrong information frequently creeps into medical charts

This study made me think about all the times I have seen flat-out wrong information in the medical records of my clients. One case particularly came to mind.

I represent the family of a 60-year-old man who died in a Sugar Land, Texas hospital. It is a really strange and sad case.

This man had had a stomach ache for three or four days after attending a party on New Year’s Eve. After the New Year holiday, he returned to work, but over-the-counter medications did not relieve the pain. His co-workers suggested that he go to see a doctor.

He did not have a regular doctor, so he went to a Fort Bend County, Texas clinic, where he was seen by an internal medicine doctor, who sent him to the emergency room.

At the emergency room, the care was brutally slow. It completely shocked his family that he passed away after a few hours at the hospital. After all, he had been walking around, driving, and working the same day.

His death certificate says that he died of an acute gastrointestinal (GI) bleed, with a contributory cause of ethanol (alcohol abuse).

This is confusing because the hospital’s own testing came back negative for alcohol. Where did this idea of alcohol abuse come from?

Our office ordered more medical records to see if there was any truth to this. A month earlier, the man had gone to another Houston-area hospital to get seen for increasing shortness of breath. In a consultation done during that hospitalization, the medical record says that he denied any alcohol abuse.

We finally traced it down to that doctor who saw him and sent him to the ER. This doctor only saw him once. Apparently during their brief conversation, they discussed that he had had some alcoholic beverages over the New Year holiday.  Then, without any explanation, the doctor wrote in his chart that he had a problem with alcohol abuse.

When this man went to the ER, he told them that he was sent there by the doctor. Apparently, after he died, the emergency room staff called the doctor, who provided them this incorrect information. That is how it ended up on his death certificate.

Three ways to get correct information in your medical records

Every time you see a new doctor, it is worth having a brief conversation going over your medical history, either with a nurse or with the doctor. Here are some things that you should cover.

First, make sure that your medication list is complete and accurate. Include any medications that you regularly take or that you have taken within the past month. You want to avoid any drug-drug interactions.

Second, explain what brought you to the hospital or doctor’s office that day. This is called the history of present illness. Provide details about how long you have had the problem and what specific symptoms you have.

Third, tell them about any other doctors you regularly see and why, as well as any chronic medical conditions that you have.

Our medical malpractice attorneys are here to help

If you, or someone you care for, have been injured because of poor medical care, then call 281-580-8800, to schedule a free consultation with the experienced medical malpractice lawyers at Painter Law Firm.

Robert Painter

Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.

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