Beware digital medical records

David J

 Digital medical records are a great advance in medical care. The patient, or advocate, doesn’t need to repeat the history every medical visit. 

But beware; a mistake in one provider’s notes will carry over to every subsequent visit. My wife had a bad experience the last month, which was actually caused by a mistake made several months ago. Most of my wife’s meds were prescribed and managed by her psychiatrist. There were frequent changes of meds and dosages, that he documented and I implemented. I also reported all of these medications and dosages to her PCP, who would record them in EPIC (MyChart). The mistake happened when I reported a med change, which the PCP recorded in her notes, but the med list was not updated. Flash forward to my wife’s admission to memory care. The MCF wanted a form completed by her PCP, summarizing her current medical condition including current meds. So the incorrect information was given to the MCF, and even though I had given the correct information to the hem, they just dtuffed it in the file and went by what the PCP had sent. 

So I discovered all this yesterday, after my poor wife had to endure 5 weeks of overdose and two hospitalizations. There will be no long term effects, but the last 5 weeks have been terrible for my wife, and very stressful for me. I have already spoken to the MCF about the heir error, and will talking to her PCP today. This is posted as a cautionary tale, not a request for advice. 

Crushed

David J wrote:

 Digital medical records are a great advance in medical care. The patient, or advocate, doesn’t need to repeat the history every medical visit. 

But beware; a mistake in one provider’s notes will carry over to every subsequent visit. ...... This is posted as a cautionary tale, not a request for advice. 

Let me assure you that it is even more common  in non electronic medical records, 

  

JJAz

David,

We had similar problems at every step along the way and it was ongoing.  I got in the habit of verifying meds being given DAILY (look at the computer screen yourself) when in the hospital and weekly (minimum) in other situations.  I caught many mistakes along the way.

Ed1937

David, I'm sorry you had to endure this. It really shouldn't be that hard to get the records right for everyone to see.

amicrazytoo

Thank you! I appreciate the heads up and will be more diligent in the future. My DH ran out of some of his blood pressure medication, he threw the bottle away without me knowing. Luckily we went to his PCP for a follow up and discovered it listed in his chart, but he had no been taking it for some time, his reading was 106/60. Turns out he no longer needed that medication.