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Communication is Key to Ensuring Accurate Medical Records

The Doctor's Office, October 2, 2008

Approximately 80% of medical records contain inaccurate information, posing serious health risks for patients. Many physician practices and health systems simply do not update medical records on a regular basis, thus leaving them incomplete. To ensure the safety of patients and eliminate potential liabilities for practices and hospitals, medical records cannot be overlooked.

Communication is key in ensuring that medical records are as accurate and up to date as possible. More organized recordkeeping is crucial in the fight for accuracy.

Physicians should be checking with patients at each office visit about health conditions that may have changed, changes in disease or disorder symptoms, and other physicians patients might be seeing, says Paula Griswold, executive director of the Massachusetts Coalition for the Prevention of Medical Errors.

"This is a good opportunity to open the lines of communication," she adds. Although the responsibility to keep records up to date lies primarily with healthcare providers, Griswold says patients should be held equally accountable.

"Practices should think about asking patients when they come in, while they're in the waiting area, if there have been any changes since their last visit," Griswold says, noting that there is not always ample time to discuss such matters during the actual visit with the doctor.

Physicians can use the appointment reminder call to ask patients to be ready to share any health-related changes with the doctor, such as new medications they are taking. Creating a medication form for patients to fill out can also help ensure that the information in the records is accurate and up to date.

Griswold says healthcare providers should additionally urge patients to carry with them a list of prescribed and over-the-counter medications they're taking and what disorders and symptoms each drug is treating. She does this for her father, making sure to update the list when anything changes.

Taking the time to check on changes, ask about concerns, and talk about how the patient is generally feeling is a good idea too. "People tend to be concerned with breaches to privacy and identity theft," Griswold says. "But you can have breaches to a patient's safety too with inaccurate records."


This article was adapted from one that originally ran in the October 2008 issue of The Doctor's Office, a HealthLeaders Media publication.