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Checking the Electronic Records

Apr 23, 2012

I read last week’s Disaster Averted and it made me realize how things that we assume are correct are often not – DJ

Our practice had recently converted over to electronic medical records and we had spent considerable time inputting data, scanning lab reports and completing prescribing records. We also started including a registry form with each chart, the purpose being to make sure we could keep up with things like eye exams, referral appointments and education classes….

I was in an exam room with one of my older patients with diabetes and was reviewing her lab values on the computer. Her last two A1c’s had been 6.8 and 7.0 respectively and when I looked at her newest lab she had jumped up to 8.1. I started by asking what had happened and why the increase. Questions like had she stopped taking her medicine, started a new medicine from her pulmonologist, gone off her diet, or changed her activity levels, were all met by constant no’s. I asked her if she had her meter and she got both her meter and log book out and they showed consistent monitoring and readings that were much lower than her new A1c indicated.

I could not figure out what was going on and the patient was becoming very worried that something serious had happened. I relooked at the latest lab report on the computer to see her serum creatinine and BUN tests and that is when I figured out what had happened.

The name at the top of the lab report was Mary S. DOB 11/19/1944 and the patient I was seeing had the same first and last name with a DOB of 7/18/41. Apparently when we were scanning in lab reports we had matched these to the wrong patient. A quick call to the lab that did her last A1c solved the problem as the correct A1c was 6.8.

Lesson Learned:

Many offices are converting to electronic records to meet Medicare and other insurance guidelines and older records are often scanned in to the new chart. With the volume of data to be copied it can be very difficult to be 100% accurate. If you have scanned records in a chart take the extra 10 seconds to make sure that they are assigned to the correct patient.

E. Cohen, MD
Columbus, OH

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Copyright © 2012 Diabetes In Control, Inc.

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