The Impact of Incomplete Patient Records on Care

By Your Health Magazine Contributor

Your Health Magazine Contributor

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The Impact of Incomplete Patient Records on Care

Modern medicine brings together specialists in multiple disciplines to deliver quality care. Typically, patients have a general practitioner who manages their overall health, and periodically, they receive referrals to see specialists as needed. In the process, they may visit an ever-growing number of outpatient facilities and hospitals. The only way such a care arrangement can work is if there is a single, unified set of patient records that every practitioner updates. Otherwise, patients could receive conflicting or even dangerous instructions, medications and more. To elaborate, here is a look at the impact of incomplete patient records on care.

Why Accurate and Complete Patient Records Matter

Patient records are at the core of how medical practitioners make decisions. They rely on accurate, up-to-date information about prior diagnoses, medications, allergies, lab results and more. Without that information, delivering safe and effective care would be impossible. That is a major reason why many developed countries make patient record portability legally mandatory. By ensuring that all medical practitioners and facilities use common, interoperable recordkeeping systems, patients can move from facility to facility with minimal barriers.

What Causes Incomplete Patient Records?

Most of the time, incomplete patient records stem from one of three primary causes. The first is workload pressures. Doctors and medical staff face heavy workloads and have little time to spend on each patient. The result is a careful balancing act between working with patients directly and recordkeeping needs. When workloads grow too heavy, patient data entry can fall by the wayside, leading to incomplete records.

System limitations are another common cause of incomplete patient records. Although most medical facilities use recordkeeping platforms that are theoretically interoperable, data transfers are not always perfect. Additionally, staff members in different facilities may use differing language that recordkeeping systems cannot reconcile. Some facilities may not emphasize detail, while others do, leading to inconsistent records. And of course, system outages and failed data transfers are always possible.

Finally, patients themselves can cause incomplete records. Much of the data that initially enters a patient’s chart comes from intake forms. Key information, such as allergies, existing diagnoses and medications, comes from the patient’s responses to a questionnaire. If they omit anything, their records may lack important data from the beginning.

Systemic Contributors to Incomplete Patient Records

Sometimes, a medical facility will suffer from systemic or organizational issues that lead to inconsistent patient recordkeeping. For example, a facility’s choice of electronic recordkeeping system can play a major role. Cumbersome or unintuitive user interfaces can make errors and omissions more likely. Additionally, systems that overload users with alerts can cause distractions that make keeping accurate patient records nearly impossible.

The training that staff receive on operating electronic recordkeeping systems also plays a part in the ultimate accuracy of patient records. If staff misunderstand how the recordkeeping system works or are not aware of how to access all available data fields, information will inevitably get left out.

Facility recordkeeping policies also affect the quality and completeness of patient records. If a medical facility does not specify exactly what data to record and when, employees may develop inconsistent recording practices. Where one doctor may record voluminous patient data, a lab technician in the same facility may resort to shorthand. The result is widely variable record quality.

How Incomplete Patient Records Lead to Treatment Errors

The greater the inaccuracies in a patient’s records, the higher the odds that a clinician will make mistakes based on faulty assumptions. Missing allergy and medication information can be especially dangerous. In those cases, doctors and other medical staff may prescribe medication that could harm a patient. Other record issues, such as missing diagnostic test results, can lead practitioners to misinterpret symptoms or order costly, duplicative testing. It can also lead to delays in treatment. The bottom line is that incomplete patient records decrease the quality and timeliness of care and undermine patient safety.

Best Practices for Avoiding Incomplete Patient Records

There are multiple ways that medical facilities and patients themselves can work to avoid incomplete records. Patients can gather as much baseline data as possible about their health to avoid omissions when visiting a new doctor or facility. That way, they can call out any notable omissions whenever they visit a new facility or provider.

Medical facilities can also implement best practices to improve patient recordkeeping. One is to create standardized documentation protocols. These should include exactly what data every employee must record at every patient interaction. They should also include baseline language requirements to ensure consistency. It is also a good idea to build recordkeeping time into employee schedules to ensure they have opportunities to perform the work. Ideally, medical facilities should also standardize training around patient recordkeeping and hold periodic refresher courses to reinforce standards with all staff members.

The Takeaway

The bottom line is that both patients and medical facilities and staff have roles to play in maintaining complete and accurate patient records. They should work together to avoid information gaps and maintain a high standard of care. However, patients should always be mindful that they have limited control over the quality of their own medical records. It is always possible that recordkeeping gaps could lead to issues with their care. When that happens, it may be necessary to work with a team of tireless medical malpractice attorneys to safeguard their rights, especially if recordkeeping problems led to injuries due to delayed care or inappropriate medication prescriptions.