“Chart lore” refers to an instance where inaccurate information gets put into a patient’s electronic medical record and carried forward for so long that it’s assumed to be true. This could happen if a doctor labels a patient with a specific diagnosis, then with auto population of information into clinical notes, the incorrect diagnosis or information gets carried forward and automatically included in subsequent clinical notes. Incorrect diagnoses that persist in medical records can lead to patients receiving unnecessary treatments, miscommunication among providers and patient confusion.
Deeper Dive
Surveys show that most health care providers admit to using copy and paste functions when writing clinical notes, without verifying the accuracy of the information, according to an opinion article in STAT news. For example, they may copy medical histories from other physicians or chart notes from a patient’s prior hospitalizations. This actually may help health systems recoup more insurance money if patients have more diagnoses, the article said. The chart notes with unnecessary and often copied details, can cause physicians to make diagnostic errors.
What can patients do if they suspect inaccuracies in their records? There are three approaches to take, according to a recent blog post for pilots:
- Call the medical records department at your health care institution and request your records.
- Schedule an appointment with your doctor to review/correct any issues in your records.
- Log in to the patient portal and review records directly from your computer or smart device.