A friend once told me that when her PCP retired she went to establish care with a new physician, and as he looked over her records, he asked if she had ever been worked up for her infertility. Startled, she asked what made him think she was infertile. It turned out that the PCP who had treated her since childhood had recorded that she and her HUSBAND had been married for 5 years, did not use contraception, and were childless. In fact, my friend and her WIFE were discussing conceiving and raising a child together.
Johns Hopkins published a study in 2016 (URL shown below) estimating that more than 250,000 deaths per year in the U.S. are due to medical error. This would make medical error the third leading cause of death, following only heart disease and cancer. How can careful charting help minimize errors?
One of the easiest ways to reduce the introduction of inaccurate information into a patient’s medical record is to verify that you’re entering information in the correct chart! When working in a fast-paced, real-time environment, it’s not uncommon to have multiple charts open at once and possibly several notes you’ve jotted down to go back and enter when you get a chance. PRO TIP: Develop a strategy in your workflow that allows you to keep track of which chart you’re working on, especially when you go back later to enter or revise information.
Information bloat and overdocumentation can often be barriers to providing the best possible care. Busy physicians aren’t inclined to wade through huge paragraphs of prose, no matter how lyrical or beautifully written they are. A January 2017 publication (URL shown below) by the National Institute of Standards and Technology pinpoints “copying and pasting” as contributing significantly to overdocumentation and even illogical content. As useful as this function is for allowing the easy and efficient reuse of information without having to retype it, how much of the information is relevant? PRO TIP: When copying and pasting, ALWAYS review and update the text and remove any extraneous and irrelevant portions.
Faulty assumptions can lead to mistakes when documenting a patient’s complaints and/or history. A common error can be to rely on what the receptionist has entered as the reason for the encounter or on what the medical assistant lists as the chief complaint. Sometimes the patient has misrepresented their reason for presentation, or the medical assistant has entered the patient’s (incorrect) self-diagnosis as the chief complaint. PRO TIP: Always rely on interaction with the patient to establish the facts of the encounter.
What are some tips you have for avoiding medical errors in the EHR?
https://nvlpubs.nist.gov/nistpubs/ir/2017/NIST.IR.8166.pdf (This site is temporarily unavailable due to current government shutdown)
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