Making Sure Your Electronic Medical Records are Accurate

Making Sure Your Electronic Medical Records are Accurate

A solid, dependable, patient-doctor relationship sure makes good health easier. Study after study shows that when patients trust, and are comfortable with, their doctors it has measurable health benefits. Not only are you inclined to share more information with your docs, it also makes a difference in how you respond to treatment—improving your compliance with prescribed therapies and boosting your healing and recovery! 

That’s why it is so important that your medical records, especially now that they are electronic and shared between many docs, are accurate. You expect them to contain all your basic vital info (height, weight, age, blood pressure, various cholesterol levels, glucose, some hormone and inflammation markers and perhaps levels of some key nutrients, like vitamin D, B12 and an omega-3 index).

But you should expect your electronic medical record (EMR) to contain much more: Information about your symptoms, lifestyle, the medications and supplements you take, past and present reactions to medication and your concerns and even objections. After all, it takes a full range of data when passed, for example, from your primary care doc to a specialist, for that specialist to understand your baseline—and build your specialized diagnosis and treatment. And if that’s not done, the chances are you aren’t going to be as happy with the treatment process—or even the outcome—as you should be.

Unfortunately, a couple of studies reveal that EMRs are not meeting those expectations. A 2014 study in the journal Plastic Surgery found that in a sampling of Canadian plastic surgeons almost 25 percent of the information fields on EMRs where incomplete and 1.4 percent were inaccurate—especially about current medications, medical history and medical allergies. And a study from the University of Michigan’s Kellogg Eye Center found that the symptoms and info patients entered on their pre-examination questionnaire and the information put into their EMR after talking with the doctor contained what the researchers called “notable differences”! Looking at the records of 162 patients, the researchers found agreement between pre-exam questionnaire and EMR for only 38 of the patients!

One example, among patients who had noted concern about glare (that’s a big deal when it comes to identifying cataracts and other eye problems), 91 percent didn’t have mention of it on their EMR. The cause for the omission wasn’t clear. Was there a discussion, but the info was never inserted into the EMR? Or did the patient forget to mention glare to the doctor, since it had already been mentioned on the questionnaire? 

Not sure. But one thing is for sure—it means as a patient you have to be attentive to your EMR! And good docs don’t mind if you ask questions.

There are four ways you can increase the accuracy of your electronic medical record:

  1. Repeat in conversation everything you’ve written down. Don’t just assume your hand-written notes will make it into your EMR in a timely fashion.
  2. Be organized and have all your current info with you. That should include a list of your meds, supplements, recent test results, diagnoses from other doctors, etc. This info should always be current in your EMR. Also bring a list of questions you want to cover during the appointment. This can generate pertinent info that belongs in your EMR.
  3. Be assertive and collaborative. Let the doctor know if you still have questions. If there’s not time to address them, then ask if an additional appointment can be set up or if other staff members can answer your questions.
  4. Ask for an electronic copy or a print out of your EMR after every doctor appointment or in–hospital stay. Review the information and then if there is an error in that record, or something you do not understand in the instructions, do ask. (Places like the Cleveland Clinic automatically give you a summary of instructions from your doc as well as your medication record).

Medically reviewed in November 2018.

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