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Missing Med Records Impair Care

A new study indicates medical records are frequently incomplete. And that, says The Early Show medical correspondent Dr. Emily Senay, can lead to problems.

"If you think about it," she explains, "a medical record is like a person's life story. It tells you everything you need to know about them: what sort of medication they're on, whether they're allergic to it, if they've had a medication and it hasn't worked for them in the past. It's all recorded there: their family history, their lab results, if you send them out to a consultant and the information you get back. It's in the chart. It's all there. It needs to be there, so you can move forward and make decisions and have them handy, so you don't have to run around looking for vital information. A complete medical record is essential."

In the study, researchers asked 250 primary-care doctors in Colorado to keep track of what they were finding in their medical records: whether or not there was missing information and whether or not they felt it affected their ability to take care of the patients.

"And they found," says Senay, "that one out of seven times, or 13 percent of the time, the doctors reported there was missing information. Now, if you consider that there are 220 million primary-care visits in this country every year, we're talking about millions of times that there's information missing that the doctors needed to help take care of the patients."

She adds that all sorts of info was missing: "The usual suspects -- laboratory results, radiological reports, family history, old physical examination results. The usual things that are missing from a chart."

And that, Senay laments, could lead to trouble: "Probably the biggest consequence is a delay of quality of care. Because then what happens is you're (doctors are) on the hunt. Where are the lab results? You're calling the lab. Where is the X-ray result I sent the patient for? I asked the orthopedic surgeons to look at the patients and I can't find their consult. I need to get it. Now I'm on the phone for half an hour trying to get in touch with somebody. And obviously, in the worst-case scenario, it can lead to complications, such as medication errors and other more serious problems. So it's important that it be complete."

What can doctors and patients do?

"Two interesting things they found," Senay says. "They found doctors in rural settings have less of a problem, and the reason for that is pretty obvious. They have less people they need to deal with. They know probably the guys in the laboratory. They know the orthopedic surgeons.

"They also found that doctors who had electronic medical records had less of a problem. So obviously, moving into the electronic world is one way to reduce this, but patients have a role to play, too.

"Everybody has to know what medication they're on and why they're on that medication, know what the dose is, know who prescribed it for them, and have the information handy. There are even medical record systems you can buy that will help you keep your own accurate medical records so you don't get into trouble.

"Keeping your own records is always a great idea. I always recommend that."