Poor record keeping, including incomplete documentation, ranks among the top 10reasons that physicians get sued — and rightly so.
While more and more doctors offices are moving toward computerized records that allow them to track your health history, send your prescriptions directly to the pharmacy and keep an updated list of your conditions, the electronic system is far from perfect.
The computerized systems do eliminate one area of concern that used to cause a lot of medical mistakes: illegible notes and scribbled lists of symptoms jotted down by doctors with notoriously poor penmanship.
However, the new computerized systems also bring new complications: a prescription can be deleted out of your records with a single keystroke, a prescription with a similarly spelled name could be substituted off of a drop-down list for the drug you actually take or the wrong dosage can be clicked.
What other ways can your medical records get mangled electronically?
— If paper files are being transcribed into an electronic system, the transcriber may omit important information, especially in thick files.
— If paper files aren’t being transcribed, that means that the office staff is taking all the information to complete the electronic form from the patient — who may not remember his or her entire medical history accurately. Many may not bring their medication with them or know their dosages.
— Erroneous information can be carried over from one section to the next that way using the “copy and paste” functions, unless they are disabled.
— Frustrated doctors or nurses who are dealing with an unwieldy system may skim through pages of questions with the default “no” key on, rather than taking the time to fully assess the patient.
— Information can get entered into the wrong box. For example, a physician who puts a penicillin allergy into an allergy box in the medical records would be alerted if he or she tried to prescribe penicillin to that patient — if he or she put the information into a note instead, the record won’t give the alert. Physicians may rely on the alerts more than they do their own review of the records, and patients could suffer.
If you’ve suffered medical harm as the result of negligent record keeping, consider contacting an attorney promptly.
Source: impertinentremarks.com, “10 things that get physicians sued,” accessed April 19, 2017
