Image: Dr. Richard Botney
Rick Bowmer  /  AP
Dr. Richard Botney, an anesthesiologist at Oregon Health & Science University, was surprised to find an error in his own chart.
updated 11/21/2007 2:47:35 PM ET 2007-11-21T19:47:35

The recent chatter on a popular social networking site dealt with a problem often overlooked in medicine: mistakes in patients’ medical charts.

The twist was the patients were doctors irked to discover gaffes in their own records and sloppy note-taking among their fellow physicians.

The frank dialogue on a doctors-only Web forum opened a window into a little discussed topic among physicians who find themselves on the other end of the stethoscope.

Take Dr. Richard Botney, who swapped experiences with fellow doctors. Several years ago, Botney visited a specialist to check out a bothersome lump in his cheek. He took some medicine and the problem went away.

Out of curiosity, Botney thumbed through his chart and was surprised to find a note from the doctor saying he had a stroke.

“I never even had the symptoms of a stroke. No visual changes, no weakness, no numbness, nothing,” Botney, an anesthesiologist at Oregon Health & Science University, said in a telephone interview from Portland.

Mistakes not uncommon
Medical chart blunders are not uncommon. Sometimes, the mistakes can be harmless, but others such as an inaccurate diagnosis or a wrong medication could have serious consequences.

Errors can creep into medical charts in various ways. Doctors are often under time pressure and may find themselves taking shortcuts or not fully listening to a patient’s problems. Others rely on their memory to update their patients’ files at the end of the day. Other mistakes can arise from illegible handwriting or coding problems.

“There is an implicit trust,” said Gerald Kominski, associate director of the UCLA Center for Health Policy Research. “Most of us want to believe our doctors are hearing what we’re saying and are accurately reporting that in our medical histories.”

Dr. Jerome Groopman, author of “How Doctors Think,” said the onus is on doctors to check the accuracy of records with first-time patients even if it takes several visits.

“You need to force yourself as a doctor to pause and to look meticulously at the record — to think, to question and to verify,” said Groopman, professor of medicine at Harvard Medical School.

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The online doctor’s Web site, Sermo, tackled the issue of medical chart accuracy this summer.

Posting under screen names, one physician with multiple sclerosis wrote about having trouble getting an insurance company to pay for a drug after the chart incorrectly noted a diagnosis of “multiple brain tumors.” Another who took over a practice had to overhaul the charting system after finding errors in the old records. A third who had had several operations was shocked to see results of physicals and other tests in the medical charts that were never performed.

The American Medical Association, which represents doctors and medical students, doesn’t have a specific project aimed at improving medical charting, but it’s always looking at ways to better patient care, said Dr. Robert Wah, a board trustee.

Paperless fix?
A possible fix is to go paperless. But electronic medical records are expensive and sometimes different systems don’t talk to one another. Only about 10 percent of doctors nationwide use some sort of electronic system.

While electronic records can cut down on medication and transcription errors, it’s not a panacea.

“You still need someone who’s listening to the patient and deciding what needs to go in the records,” said Dr. David Blumenthal, director of the Institute for Health Policy at Massachusetts General Hospital.

In the meantime, health experts recommend that patients periodically check their medical records as they would their credit report, especially if they have a chronic condition. Patients have the right to get a copy of their medical records under the federal Health Insurance Portability and Accountability Act, or HIPAA.

Botney, the 52-year-old doctor whose records said he had a stroke, still doesn’t know how the error occurred. He flagged the mistake to his specialist, but hasn’t taken further action since the error hasn’t affected his insurance or disability coverage.

Despite his experience, Botney said he is impressed with his current doctor, who took an hour to review his chart during the first visit.

In his own job, Botney said he takes copious notes in visits with patients and then reads them back.

“They expect that what they tell the doctor is what’s going to be charted,” he said.

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