(From the August 2014 Issue of MedStat)
Situation: Hospital staff and providers are confused as to what to do when they find inaccurate information in the electronic medical record. They are unsure as to the process for reconciling these discrepancies.
Background: Multiple providers and staff access the patient electronic medical record (EMR) from a variety of locations. Medication reconciliation is required on each visit and transfer of care to ensure accurate medication information is captured and appropriate care is delivered. Additionally, medical and surgical history is reviewed for similar purposes.
Assessment: Through chart review and discussion with staff and providers, we frequently find inaccurate information in the EMR. This is especially true for medication records and patient history. These inaccuracies occur for two reasons: 1) the family does not provide the accurate information because they do not know it; or 2) staff simply entered the wrong information at a previous encounter. Regardless, the staff who identify the inaccurate information are often reluctant to change or edit information entered by other health care workers. Furthermore, they may not know how to or may not feel empowered to amend the record.
Recommendation: If you are unable to resolve the discrepancy in your area or section, contact Health Information Management (HIM) at HIMdataintegrity@NationwideChildrens.org for further assistance.