Why is it important to ensure your medical records are factual?

Answer 1

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Answer 2

Besides for insurance and statistical purposes, an accurate health record is critical for appropriate medical and nursing care. Perhaps the best way to understand why accuracy is important is to list some examples.

• Two women have the same first name, middle initial, and last name. But woman #1 has had a serious reaction to antibiotics, and Woman #2 has never taken an antibiotic. Both women are admitted for routine surgeries: Woman #1 for a hysterectomy (removal of uterus), and Woman #2 for back surgery. Woman #1 develops a post-op infection. But the charts are switched because of the identical name so no one knows that Woman #1 shouldn't get a certain antibiotic. After the first dose, she develops shortness of breath and almost dies.
• A busy nurse does admission forms for several patients admitted for various reasons. Mrs. Somebody Smith's chart states she was previously addicted to narcotics, but this information is wrong. Because she is in a teaching hospital, she sees a number of Residents; none know her personally. Each refuses to give her anything stronger than Tylenol because the Doctors "don't want her addicted again". Mrs. Smith suffers strong pain for several days before finding out about the mistake. But when she tries to correct the information, no one believes her; they think she's a "druggie" who is lying and lying about being in pain, so they still won't give her a narcotic. Only after she calls her family doctor is she able to get anyone to believe her! By then, she suffered for 4 days.
• A busy, rushed Surgical Resident writes in the patient's chart: "Cleared for right above knee amputation." But, the patient's leg with necrotic tissue (dead tissue) is his left lower leg. No one marks the correct leg before surgery. The patient has no reason to think that a mistake could be made; after all, everyone can SEE the black tissue on his foot and lower leg. As all patients, he arrives in the operating room covered with a sheet. The Head Nurse flips through the chart, and sees "right" leg. After the patient is given anesthesia, they drape and cover all but his right leg. The leg looks diseased as a complication of Diabetes, but it isn't yet necrotic--nor as necrotic as his left leg. But the surgeon doesn't pull up the drape to compare the legs. Instead, he removes the right lower leg. A nurse later discovers the error. Now the patient will still need his other leg removed. Rather than a single amputee, he'll be a double amputee.
• A diabetic receives specific units of insulin before meals. But a nurse wrote the amount incorrectly on the med sheet. The patient receives double the insulin and almost dies because his blood sugar drops to a life-threatening level.
• A doctor suspects child abuse about Couple A against their infant son and reports his findings to child welfare. But Couple B with an infant son are also seen in the same office. Charting after-hours, the doctor records his exam on the wrong chart. A couple years later, the doctor dies unexpectedly and a second doctor buys the practice, using the charts the deceased doctor made. Couple B can't understand why this new doctor treats them so negatively. When they request their son's records to go to a new doctor, they are shocked to find they have been accused of child abuse. Because the original doctor is dead, no one realizes that it could be a mistake in charting. This wrong information follows these innocent parents until their son is a teenager.

Whether about medications, conditions or diseases, or med Allergies, etc., every chart error can cause irreparable harm to a patient--or in the case of an infant, can affect the infant's health and parents' reputations.