be careful what you click on

 

 



 

Random rant:

 

Last week I presented to a specialist as a new patient. I had to see him because of the potential toxicity of a drug I've been taking for years. I was lucky enough to have snagged an appointment right away. Unfortunately, that meant I had to fill out all the necessary paperwork when I arrived at the office--demographics, insurance information, and medical history.

 

"What the world really needs

is more love

and less paperwork."

~Pearl Bailey~ 

 

Before I even started, I was called back to the exam room...meaning the medical assistant had to run through my information and get it into the EMR before the doctor came in. It all went smoothly until she asked me how long I'd been taking said toxic medication:

 

MA:  What year did you start taking it?

Me:   I really don't remember. I've been on and off it a couple of times over the years.

MA:  But when did you first take it?

Me:   I have no idea. I'd be guessing. Maybe twenty years ago.

MA:  And when did you go off it?

Me:   (sounding just a tad exasperated) I don't remember. I don't know. I went off and then back on it several times.

MA:  But I need a date. I can't go on without the date. At least, the year.

Me:  (Thinking, so I should just make something up for you? Fabricate a date? OK, then...) Let's pretend I started taking it in 1987. (I could have said 1887 and she probably would have been satisfied...)

MA:  OK, good.

 

This may sound like an inconsequential issue to some of you...but this is the kind of thing that can lead to falsification of the medical record...inaccuracies that are prompted by a computer program. Permitted by it. Even encouraged by it.

 

"Without strong safeguards, the dream of

electronic health information networks

could turn into a nightmare

for consumers."

~Edward J Markey~



 

This isn't the first time something like this has happened to me. My own medical record includes a preop exam that states my neurological exam was normal...when it wasn't checked at all. Thankfully, I didn't have a seizure or a stroke during the procedure. How would they explain that?

 

The point is that inaccuracies in the medical record can spell disaster for a provider who is involved in a malpractice claim. Attorneys are going to question you about the details of the neurological exam you recorded but failed to perform, or the cardiac exam you said was normal even though the patient has a known mitral valve prolapse. Casting doubt on your reliability. Errors can mislead consultants and other health care providers. The patient may suffer. 

"We should all be aware

--even alarmed--

about the gaps in critical information

that may exist in any patient's

computerized medical record."

~Linda Harlzberg, MD~





Be careful about what you click on in your EMR.

 

"We strive for error-free medicine

in a world that is sometimes

all too human."

~Michael C Burgess~

 

jan