Patient Access to Medical Records Could Improve Medical Record Accuracy

Medical Records

The primary role of healthcare organizations is to provide quality patient care and any minor error can lead to severe patient injury or death of the patient. These errors could cause huge financial loss like penalty ranging from thousands to billions of dollars, along with psychological and emotional stress. So, to avoid medical errors, healthcare organizations should have proper rules and regulations and remain HIPAA-compliant to ensure that the medical records are accurate. To ensure accuracy in medical documentation EHR was introduced, however, it has led to other serious issues like typos, error with copy-paste functions, dropdown menu and auto complete feature, missing or incorrect entry etc along with physician burnout due to the excessive medical documentation process. Medical practices and hospitals are now hiring a medical transcription company to convert physicians’ dictation into accurate records and upload them into EHR using HL7 interface.

A Study Shows Common Types of Patient-reported Errors

A study “Frequency and Types of Patient-reported Errors in Electronic Health Record Ambulatory Care Notes” published by JAMA Network shows the patient-reported errors in their medical records. In the US, over 44 million can access their ambulatory visit notes online. Some studies have shown that patients have identified documentation errors in their medical notes and how these may inform patient engagement and patient safety. So, this study aims at assessing the frequency and types of errors identified by the patients who have read their ambulatory notes.

The study stated that errors in EHR are common and half of them are related to medication. Physician burnout from excessive medical documentation leads to inaccurate medication list, errors by copying and pasting from older records and errors in examination findings. EHR also lacks critical information because of limited interoperability among health care sites.

When patients can access their medical records, it enhances patient engagement and also improves patient safety and care quality. Patients say that they understand the notes very well and reading the notes helps them to remember the next step, enables timely follow-up, and provides information to family or friend care partners.

A total of 36,815 patients received survey invitations and 29,656 participants responded. 22,889 patients read one or more notes in the past 12 months. Out of 22,889, 73.4 percent reported reading notes for at least one year and 49.8 percent reported reading 4 or more notes. Among all patients that participated in the survey, 80.5 percent reported that they were confident in their ability to find mistakes whether or not they reported a mistake in their notes. In total, 4830 of 22,889 note readers (21.1%) perceived a mistake in their notes. Out of 4830 patients who found mistakes in notes, 2043 had serious mistakes and 480 cases were very serious.

Categories of Mistakes Described by Patients

  • Diagnosis-related mistakes (27.5 percent): Patients stated that diagnosis-related mistakes like perceived errors in specific medical diagnoses, including conditions that patients did not have, diagnosis that patients had and thought were relevant but were not recorded, problems or delays in the diagnostic process, or inaccuracy of existing diagnosis.
  • Medical history (23.9 percent): Some patients said that mistakes in their medical history like marking the wrong symptoms, mistakes in dates or types of operations, including documentation of operations they reported they never had. They have also had contradicting notes among practitioners.
  • Medications (14 percent): In this category, patients experienced mistakes such as prescriptions of medicines that the patient was no longer taking, missing new prescriptions for medicines that the patient was taking, wrong dosage and so on.
    There were cases of medication allergies, and cases like omission of severe or anaphylactic allergic reactions.
  • Test Procedures and results (8.4 percent): Patients found that wrong test results were entered in the notes; some practitioners were unaware of more recent results that existed; mistakes in radiology test results or physician summaries of radiology reports, which make it highly challenging to determine whether the patient’s condition improved or worsened.
  • Other errors: Other errors, reported by 53 participants (14.9%), most commonly reflected errors stemming from copy and paste of prior electronic notes, and billing mistakes, like wrong codes implying conditions the patient reportedly did not have.

One solution to this problem is notifying the practitioner about the perceived error. Some patients commented that perceived errors led to emotional or psychological distress, delayed diagnosis or treatment, or lost days at work. Some other patients had to go through frustration, exhaustion etc trying to correct the error.

The study identified that giving patients access to their medical records would improve medical accuracy and patient engagement in patient diagnosis. This helps to ensure better patient care in the healthcare set up. The main aim of the healthcare industry is to provide quality and accurate medical records. So, investing in a reliable medical transcription service is important to increase the quality of patient care and to ensure error-free records.