It’s the Wrong Chart, Gromit!

No, not just The Wrong Trousers.

A few weeks ago I looked at an entry in a patient’s electronic record and discovered to my horror that I had copied the content from a text conversation with the family member of another patient. I copied the entry to the correct chart, but when I asked the EMR vendor to remove the erroneously placed entry they refused. I persisted, pointing out to them that if I released the chart to the patient I (we?) would also release information about another patient without their consent. After several weeks they relented and “unsigned” the entry which allowed me to delete it, just in time, too, as the patient may want a copy of the chart soon.

It soon occurred to me that to prevent this simple error I could review every chart released page by page. I also recalled reviewing charts for past independent examinations and finding pages from other patients’ records. With paper charts I could easily just move the erroneous page from one manilla folder to another. If I noticed the error.

But electronic records don’t come in pages. You might easily overlook the stray note.

One can also send email to the wrong patient, or even place a letter in an envelope intended for mailing to a different patient. Texting seems safer than email, and now I leave the name off of routine correspondence entirely. I can still hand Joe a superbill with Judy’s name on it. Ditto a paper prescription, but fortunately I rarely write those anymore.

When patients can view their own electronic record online any time they wish, which I advocate, how will we catch such mistakes?

Until I find a way to stop making mistakes altogether, (Don't hold your breath.) I plan to use a disclaimer like you may have seen in faxes or emails, but with some added language. Who knows whether this will protect me, and I hasten to add that this does not constitute legal advice. I suspect it will continue to evolve; please comment if I omitted something, but as of now:

This information has been disclosed to you from records which may be protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

These records may contain health information about individuals who have not authorized its release to you. If you find such information, or if you are not the intended recipient, please remove and return or destroy any such records and notify us immediately.

These records may not be complete.

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