Rushed doctors can place outdated, inaccurate information in your electronic medical record

 

Study shows only 18% of a typical doctor's note is written by the doctor. Where does the rest of it come from?

 
June 1, 2017

How reliable is the information that your doctor is using to diagnose and treat you? Is it comprehensive? Is it detailed? Is it even accurate?

As a Texas medical malpractice lawyer, I have handled case after case where there were serious medical mistakes because doctors were using incomplete and just plain wrong information to make treatment decisions for their patients.

In my experience, the advent of electronic medical records has only made this worse. I call it “information creep.” A tech, nurse, or doctor can type in some incorrect information into the electronic medical record and it creeps into future documentation for days, weeks, and even months.

Think of it like the childhood game of telephone, where children sit in a line of chairs and whisper a message into each other’s ears, one person at a time. By the time it gets to the last child in the line, the message is nowhere near what it was at the beginning. It is funny when it is a schoolyard game, but is dangerous when it comes to patient care.

I believe that part of this problem is because many doctors and other healthcare providers have gotten a bit lazy. Another part is that electronic medical record software makes it easy for this creep to occur by automatically copying information into new documentation, and by allowing doctors to cut and paste text that other people have entered into the record.

A recent study validated my opinions.

Research published online by the Journal of the American Medical Association (JAMA) found that a mere 18% of a typical doctor’s note in a medical record is manually entered by the doctor, leaving 46% copied and pasted from other parts of the medical record, and 36% imported by the electronic medical software.

To me, this is downright frightening and terrible news for anyone concerned about patient safety.

The expected purpose of a doctor’s progress note is to provide a brief, up-to-date summary of the patient’s conditions and the doctor’s assessment and thought processes.

The accuracy of these notes is important for the continuity of care, because future health care providers treating the patient will review those notes and presume that the information is accurate.

When doctors use shortcuts, like copying and pasting, in documenting medical records, it increases the risk that outdated and inaccurate information can get republished and relied on in future treatment decisions.

Dangers of bad information in medical records

When doctors rely on bad information, it can lead to dangerous and deadly results for patients. I am thinking of a tragic example right now.

I recently represented the family of a man who went to the hospital with a bad stomach ache four days after New Year’s Day. He had gone back to work on January 2nd, and drove himself to the hospital on January 5th when over-the-counter medications did not relieve his stomach pain.

When he was getting checked into the emergency room, he told the triage nurse that he had attended a party on New Year’s Eve, where he ate a lot of different foods and had some alcoholic beverages. The triage nurse wrote in the medical record that he was an alcoholic, which was inaccurate.

The emergency room doctor read the nurse’s note and relied on it as being correct and truthful. Without even talking to this patient about alcohol, and ignoring the fact that he had driven himself to the hospital in the middle of the day and straight from work, the doctor started treating him with Ativan, for alcohol withdrawal.

In a testimony to the power of bad information, the doctor continued this course of treatment even after lab work came back showing that the patient had a zero blood alcohol level.

Sadly, the man died in the emergency room within a few hours of a GI bleed that had never been suspected, worked up, diagnosed, or treated.

Here are some ways that bad information can creep into your medical record and lead to danger:

∙ Errors in what brought you to the hospital or doctor’s office. If a nurse or tech does not get this write and placed it in your medical record, then the doctor may be clueless about what needs assessed and treated. When you see the doctor, always start over in explaining why you decided to seek treatment. The doctor needs to hear it first-hand from you, and in your own words.

∙ Mistakes in the list of medications that you are currently taking. It is important for your doctor to know about every medication that you have taken any time within the previous month. If the doctor is going to write a new prescription, then he or she needs to avoid dangerous drug-drug interactions. You can add an extra layer of safety by asking your doctor and pharmacist if the new prescription poses any risk, considering the other drugs that you have been taking. On this point, I also recommend always using the same pharmacy to fill all your prescriptions. That way, the pharmacy’s computer system can generate automatic warnings to avoid potentially-deadly drug-drug interactions.

∙ Inaccuracy in the list of your other medical conditions. Your doctor needs to know about any heart, respiratory, liver, or other medical conditions you have, as well as any past surgeries. Even if you have gone over this information with a nurse or tech before seeing the doctor, it is a good idea to share that information again directly with the doctor. It can help inform proper treatment decisions.

In short, these steps can encourage your doctor to get off an “auto-pilot” mode of copying and pasting other people’s text and impressions about you, and to start exercising expert thinking about your needs as an individual patient.

Our medical malpractice lawyers are here to help

If you or someone you care for has been seriously injured as a result of a botched diagnosis or treatment, then call 281-580-8800, for a free consultation with an experienced Texas medical malpractice lawyer at Painter Law Firm.

Robert Painter

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

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