Do medical records routinely have inaccurate information in them? As reflected in this story from the Associated Press, Dr. Richard Botney found errors in his own medical records when he, out of curiosity, took a look at them. How could this happen? Wrong information comes about in a variety of ways. Handwriting can be misread. A nurse can misunderstand a patient’s answer to a question. A physician may mis-speak when dictating his comments. A transcriber may misspell or fail to hear the dictation correctly. A patient’s charts may be mixed up or misfiled by the doctor or hospital. When you think about the many ways in which the information in a particular patient’s file can be contaminated, what is really surprising is not that a particular patient’s file contains errors but that it doesn’t have errors in it. This is, in my experience the reality. If you get a medical record of any volume, it will have mistakes in it. And, of course, that can have serious adverse effects on patients for a variety of reasons.
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