Can electronic medical records eliminate the need for accurate medical transcription? This is a question frequently asked by providers who are used to dictating their medical notes and having them professionally transcribed. Let us consider this in the light of the findings of a recent study.
Complete and accurate documentation of medication allergies is crucial for patient care, especially in the emergency department (ED). Inaccurate information will drastically affect clinical decision making and lead to suboptimal therapy. The study mentioned above, published in the Southern Medical Journal, states that there are significant discrepancies between allergy details reported in electronic patients chart and the information collected during patient interviews at the ED.
This study comparing a prospective patient interview with allergy histories documented earlier was conducted between December 2011 and April 2012 in an academic emergency department. The patients to be interviewed were adults and they had at least one documented allergy in their chart. Demographics for sex, age and race were recorded while descriptive statistics and percentages were used for demographic and prevalence data. The study evaluated the agreement between interviews and patient charts with regard to both the reaction type and the reaction descriptor.
101 patients were interviewed during a 4 month period and 235 adverse drug reactions were recorded. Around 66 women and 35 men of mean age 51 ± 17 years were included in the study. If the median number of allergy instances for women was 2, the median number for men was 1. The other important results of the study are as follows.
- With the interviews, 18 (7.7%) allergies were found that were not recorded in the chart. At the same time, another 18 allergies documented in the chart were denied by the patients during the interview.
- Some reaction descriptors were omitted from the patients’ charts, and for around 32% of allergies there were no reaction descriptors specified.
- Total profile agreement between previously documented allergies and patient interviews occurred in only nine patients.
- For overall allergies, the percentage of agreements was 85% whereas it was 50% for the type of reaction.
- The percentage of agreement between patient charts and interviews for reaction descriptors was only 50%.
As per the study, there are several reasons for the inconsistencies. The patients’ incomplete knowledge regarding their drug allergies, and the disparity between pharmacists and physicians taking medication and allergy histories, are among the prominent reasons. Pharmacists entered a descriptor for an allergy in 53% of the patient profiles, whereas physicians entered the same for only 2%. When a reaction descriptor is added in a patient’s allergy history, providers can identify medically significant reactions and prevent unnecessary treatment modifications made on the basis of incomplete information.
Another significant reason is the low agreement in allergy reporting using electronic charts with what has been reported with paper charting. The study has found many pitfalls possible within some electronic charting systems. Some EMR systems defaults the documentation of an allergy to label it as a true immune-related allergy. Moreover, these systems may not require the provider to input a reaction descriptor. The result is – over reporting of the reaction type being an allergy, and under reporting of reaction descriptors.
In short, the study implies better methods are required to properly document allergies and ensure patient safety and care even with the use of electronic medical records (EMRs). Meanwhile, providers who prefer the traditional method of dictating their notes and then getting them transcribed can consider EMR transcription and integration services to make their documentation even more accurate. Medical transcription companies in the United States offer this service. This involves transcribing physicians’ recordings and entering the thoroughly checked transcribed data into relevant EMR fields.
