I recently read some interesting statistics about the completeness and veracity of paper medical records compared to data entered into EHRs. A study was recently published in the Journal of the American Medical Informatics Association about retrospective research done on 500 progress notes from a Michigan hospital, some done on paper prior to EHR adoption and the rest after. Findings show the rate of EHR inaccurate documentation was 24.4 percent as compared to 4.4 percent in the paper records. At the same time, complete physical exam findings were left out of 41.2 percent of paper charts, while 17.6 percent were left out of the EHR.
The study was obviously very small but it points up the fact that when we need our complete medical record it may not be there and that can affect patient outcomes. No one wants to be a hospital in a city away from home and not be confident that the medical record that is conveyed to the facility is complete and accurate.
Improved training is clearly needed. At the same time, while there is increased access by patients into healthcare network portals, I’m not sure we get see enough information in there to know if our records are accurate. The little I have seen in my records showed inaccuracies. We need to do better.
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