Proper medical records are vital to ensuring the safe and proper care of every patient. Each medical professional has a responsibility to accurately log this information, and health care organizations should ensure they are doing their due diligence to obtain and maintain any relevant history of a patient.
Too often, one of the links in the chain fails. This puts a patient at serious risk of suffering unnecessary harm.
The consequences of poor recordkeeping
Insufficient recordkeeping is not a rare event. One Kaiser Health News story says about one in every 10 individuals who look up medical records online end up requesting an error be fixed. These mistakes can vary widely, but might include:
- Incorrect patient information (such as age or sex)
- The inclusion of a different patient’s information
- Missing labs or test results
- The inclusion of an incorrect diagnosis
- Unlisted medication allergies
Even a small error can have disastrous consequences. The Kaiser Health News report details a story from a man that had a mass removed from his neck. A test detected the tumor was cancerous, but that information never made it to the neurosurgeon – who told the man the mass was benign. Six months later, the patient learned untreated cancer had spread to his spinal column.
He died about two years later.
You can take some steps to protect yourself from the potential danger of mismanaged medical records. One federal agency provides some tips here, including:
- How to contact your provider
- The types of mistakes you should look for
- How to rectify any issues you discover
However, it should not be solely on your shoulders to correct the errors of others. Medical records are complex, particularly for those with a chronic health condition. At the end of the day, it is the responsibility of well-compensated medical professionals to maintain proper, accurate records that do not put patients in harm’s way.