Excerpt from Wall Street Journal – Tuesday, June 10, 2014 – Look Inside Your Medical Record and Odds Are You’ll Find a Mistake –
COMMON ERRORS IN MEDICAL RECORDS
Outpatient medical records often contain missing or inaccurate data, including:
- New prescription medicines aren’t listed, or medicines are listed that the patient isn’t taking anymore.
- An incorrect or outdated dosage of prescription medicine.
- Duplicate prescriptions for brand-name and generic medications.
- Over-the-counter remedies, such as pain relievers, vitamins or other supplements, aren’t listed.
- Incomplete or missing information about medication allergies.
- Erroneous information about treatment outcome, such as a condition that is noted as resolved but is still a problem.
- Updated information about lab results is missing.
- Details about symptoms, as reported by the patient, are missing.
- Inaccuracies in diagnosis.
- Missing information or updates from another provider.