Research has found that thousands of hospitalized patients die every year due to diagnostic errors. A Harvard Medical Practice Study reported that diagnostic mistakes were responsible for 17% of preventable errors in hospitalized patients. A recent American College of Physicians (ACP) report noted that the rates of diagnostic errors range from 10% to 15% in internal medicine and that hospitalist can play an important role in avoiding and mitigating these mistakes.
Gathering the patient’s history, findings from the physical examination, and other data is crucial for making accurate diagnoses. However, current electronic health record (EHR) documentation practices are largely governed by billing and legal requirements. Health Information Technology (HIT) errors can occur at any time due to malfunction, incorrect use, and data entry errors, resulting in information being lost, and wrongly displayed or transmitted. This can cause diagnostic errors, leading to delay or failure to treat an existing condition, or to treating a condition that was not actually present.
The ACP report points out that hospitalists are extremely important in establishing the correct diagnosis. They are the first point of contact once the patient is hospitalized and can review the decisions made up to that level. They are therefore well-positioned to detect any diagnostic errors that may have been made in the clinic or in the emergency room. Hospitalists can reduce the incidence of errors by improving their diagnostic skills. This includes:
- Taking a thorough history
- Conducting a proper physical exam
- Examining past medical history and tests done carefully
- Listening to patients and caregivers
- Ensuring that patients can contact them if symptoms change or persist
- Use diagnosis-specific decision support resources
- Pay attention to second opinions
- Communicate directly with the staff providing diagnostic test results
- Learn the causes of system-related and cognitive error and how to avoid snags
Experts say that deriving a differential diagnosis can be a very useful strategy to avoid missing a key diagnosis.
Even as specialists in internal medicine grapple with the complexities of ensuring correct diagnosis, they can always rely on professional medical transcription companies for accurate and timely documentation of history and physical reports, diagnostic and treatment plans, emergency reports, surgical reports, examination reports, laboratory reports, and more.Even with the shift to electronic clinical documentation from paper records – medical transcription services continue to be a reliable option for ensuring that information from patients’ clinical encounters and tests are readily available. It is common knowledge that copy/paste notes are very harmful to diagnostic quality. Medical transcription service providers ensure that physician dictation is correctly documented and even provide feeds to the EHR.