Telling Your Doctor About a Health Issue Doesn't Mean It Enters Medical Record

November 14, 2024
Dennis Thompson HealthDay Reporter

THURSDAY, Nov. 14, 2024 (HealthDay news) -- Don't think your doctor is always taking your health concerns seriously? You might be right.

New research reveals that primary care physicians frequently won’t write down health issues raised by patients into their medical record for future reference.

When a person initiates a discussion about a health issue with their doctor, the matter only makes it into their electronic health record 45% of the time, researchers found. In comparison, health issues brought up by a doctor during a visit are put into the record 92% of the time.

“The electronic health record [EHR] is the de facto means of ensuring continuity of care for patients,” said senior investigator Richard Frankel, a research scientist with the Regenstrief Institute in Indianapolis. “In an era in which face-to-face communication between physicians has given way to communicating via devices such as computers and smart phones, the accuracy and completeness of the record of care takes on additional importance.”

“Our findings suggest that better alignment and education about what’s said and what’s documented in the EHR will ensure that both the quality of the care being delivered and attention to the human dimension of the patient’s biological, psychological and social needs are present and accounted for,” Frankel added in an institute news release.

For the study, researchers recorded conversations between health providers and patients during office visits at five Veterans Affairs clinics in the Midwest, then compared transcripts to what actually wound up in the patients’ medical records.

The team found that most issues brought up by patients didn’t show up in the EHR notes on their visit.

In addition, nearly half the notes in the EHR referred to information or observations not found in the transcript of the actual medical encounter, researchers reported recently in the journal BMC Primary Care.

These omissions could occur because doctors don’t recognize the significance of a problem brought up by a patient, or due to forgetfulness while writing notes, the research team speculated.

Doctors also might not write it down because they think the issue has been addressed, or that it is less important than other medical concerns, researchers said.

Time crunch also might be a factor -- doctors' busy days may make it hard to complete EHR notes accurately and thoroughly.

“Although EHRs have matured in certain ways, they may also contribute to a range of errors from minor to egregious,” the research team concluded.

“Improvements to documentation should consider the roles of the EHR, patient and clinician together. Increasingly, documentation itself should become an active and interventional tool to improve care, instead of a passive means to archive an encounter,” the team added.

More information

Northeastern University has more on electronic health records.

SOURCE: Regenstrief Institute, news release, Nov. 12, 2024

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