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Electronic health records commonly found to be incomplete

Many North Carolina hospitals and medical care facilities use an electronic health care record system for their patients. Although EHRs are in many respects superior to previous methods of charting the medical history of a patient, disturbing lapses in coverage have been discovered.

Many of the problems appear to manifest in the area of mental health care. A study conducted by Oxford University researchers showed that people with mental conditions such as bipolar syndrome or depression were receiving treatment that was not appearing on their records. If a patient with one of those conditions sought outpatient therapy, then there was a better than even chance that their treatment and prescriptions would not appear in the EHR.

When it came to acute psychiatric services, nearly 90 percent were not reflected in the patient's EHR. In the face of data such as this, the study recommended that multiple sources of information be consulted as to the patient's record, and the EHR should not be relied upon alone.

A mistaken impression that an incomplete EHR represented the patient's entire medical history could easily lead to a doctor's failure to diagnose a serious illness. This type of error could result in a worsened medical condition, and in some cases it could prove fatal. However, not all medical mistakes constitute malpractice. What needs to be established is that the error constituted a failure by the health care practitioner or facility to exhibit the requisite standard of care, and an attorney representing a plaintiff will attempt to demonstrate that in part through the opinions of one or more medical experts.

Source: Science World Report, "Electronic Health Record (EHR) Found to Have Glitches in Recording Patients Data, Study Reveals", Johnson Denise, April 26, 2016

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