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What is “chart lore” and why is it dangerous for patients?

Information technology has undoubtedly improved the accuracy and efficiency of medical care. Unfortunately, it can also make it too easy for serious errors to occur – and go unnoticed until a patient is harmed.

Long gone are the days when doctors had to hand-write their patient notes. Now they simply type them into a computer. That has created very long electronic medical charts comprised of notes, records and test results that patients as well as anyone on their care team can easily access online. Not only doctors, but nurses, therapists and others often can add their own notes to this information. 

The problem is that information that’s been found to be inaccurate often isn’t removed from patient records when a mistake is discovered or a diagnosis changes. That means it can be copied and pasted until it becomes what’s known as “chart lore.”

Over half of patient information is copied

A recent study by the University of Pennsylvania Medical Center (UPMC) showed just how often portions of patient records are copied and pasted. In looking as some 100 million patient notes (33 billion words), the study found that over 50% of that information had been copied from another location. Since one of the main reasons for doing this is to save time, that information typically isn’t reviewed for accuracy. 

In another study in 2017 at the University of California San Francisco Medical Center, researchers found that even more information (over 80%) was copied. As the study’s authors noted, this “increases the risk of including outdated, inaccurate or unnecessary information, which can undermine the utility of notes and lead to a clinical error.” 

This problem can be minimized

The problem is not without solutions. Hospitals and medical practices can implement procedures to limit the amount of information that is copied, require daily or other regular progress notes and make copied information identifiable.

It’s important for patients and their families to speak up when a doctor seems to be basing a diagnosis or treatment on inaccurate information. It’s also crucial to speak up if you notice inaccurate or questionable information in your records. 

If an error was made due to the copying of outdated and inaccurate information on your medical record, that doesn’t absolve the human(s) who made the error of fault. We rely on doctors to use their education, training and knowledge to make sound decisions. If you believe you were the victim of malpractice, it’s wise to get experienced legal guidance as soon as possible.

Contact an Easton medical malpractice lawyer for more information.

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