Medical Record Errors

medical records, inaccurate medical records, medical record errors

I don’t know how many of you have ever requested and read your medical records, but you might just be surprised if you did. I have copies of all of Apollo’s records, from his birth on. They are filled with medical record errors, large and small. Some as innocent as a record from St. Joseph’s stating his birth weight as “11 pounds 3 oz” (that didn’t give someone pause?).  To the slightly more serious stating he was transported by “private vehicle” instead of ambulance, that horrible night he choked and I called 911.

Last week I received a summary of Kalina’s visit to the Hearing Loss Clinic at Seattle  Children’s. It was four pages long and at the end said…“The CT scan {done here in Bellingham last spring} was positive for bilateral enlarged vestibular aqueducts (EVA). With this finding it is recommended to also request insurance preauthorization for sequencing of  another gene…”

I read and reread that statement several times. I clearly remember being told by the doctors up here that Kalina’s CT scan came out perfectly normal. The doctors at Children’s said they wanted to review the scan themselves as a matter of form. I knew they were looking for any identifiable reasons for her hearing loss, and EVA would have offered that. I immediately called the number listed and got an answering machine, saying calls would be returned within one business day. I left a message asking for a return call and saying I wanted clarification about the CT scan. Then, of course, I began to research EVA. To make a long story short, I waited through the weekend, called and left another message Monday morning and sent an email. This afternoon I received a return call from the genetic counselor who (sort of) apologized and said, “Oh, that was the CT scan of another patient with a similar name”.  They  haven’t actually received or reviewed Kalina’s CT scan yet.

medical records, inaccurate medical records, medical record errors

When we took Apollo to Texas Children’s for his second double aortic arch division, the surgeon told us straight out, “I don’t know what I’m going to find when I go in, because his medical records don’t jive with his anatomy”. He said this after viewing a CT done in Texas. The issue begins with the very first  incision of his first heart surgery, where the original surgeon states she went between the “fourth intercostal space” when she actually went through the third. The medical record errors go all the way to not mentioning the metal clip that was placed or the reasoning behind the unusual placement of that clip. These details left the second surgeon not only confused, but guessing about the accuracy of everything else in Apollo’s records as well.

As soon as we were home from Texas and settled in I requested Apollo’s records from Texas Children’s Hospital. Several weeks later I received a slim envelope with two pieces of paper in it. Instead of Apollo’s records, I received the records of another little boy treated at the hospital. I called immediately, and they asked me to send the records back. I told them I was concerned someone else had Apollo’s records. They assured me a mix up like that couldn’t possibly happen…no one else could possibly have Apollo’s records.  I asked them to please send Apollo’s records. The hospital called twice more and sent a return envelope for the records. During the third and final call I told them straight out I would return this boy’s records as soon as I received Apollo’s. They were so very concerned about the records I had (for HIPAA reasons, no doubt) but in no hurry to send me Apollo’s records. They shipped off Apollo’s records that very day (I checked the postmark) and the other boy’s records were in the mail the day after Apollo’s arrived.

They, too, have numerous errors. Including a statement that his repairs are “consistent with Tetrology of Fallot” a severe heart defect he does not have.

I could keep going with examples, but I think you get the idea. You may think these things don’t matter very much, and some probably don’t (Apollo’s birth weight, for instance), but others are vitally important. If you are admitted to the hospital, or go to the ER, these records are what your doctors or nurses with be accessing. They will be making decisions based on these records. With such glaring inaccuracies in Apollo’s records, the surgeon in Texas had no idea what he would face when he opened Apollo up. He had no idea why the clamp was put in such an unusual place. He had to make his best guess and do the repairs from there.

In the case of Kalina and the genetic counselor, she assured me she would add an “addendum” on to her records and correct it. And that’s fine. But I don’t  think it is acceptable to inform a parent their child has a particular medical condition, because two patients “names are similar”. The genetic counselor told me this was “a reminder to completely focus” on what she was doing and not get distracted. Um…when you’re dealing with my child’s health, yes please, try to focus and be aware of what you are doing.

I would love to blame one person, or one institution, but I’ve had these experiences at all three hospitals I have dealt with in the last three years. I’m interested to hear what those of you in the medical field think of this? For those of you not in the medical field, have any of you requested your records?  Did you find them accurate?

 

71 thoughts on “Medical Record Errors

  1. Our records are completely messed up. It’s frustrating because no one wants to fix them. And then they make *ME* feel like I’m the overbearing, obsessive patient. So frustrating!

  2. We’ve encountered similar issues here. I had a surgery done and moved. When getting follow up for my medical condition a number of years later, they tried to tell me that they had not found anything during the surgery despite an indepth treatment discussion with my surgeon. Because of a medical record error. And the doctor believed the records over my recollection.
    It can make a very big difference in ongoing treatment AND in what your insurance says/does.
    My insurance has me down as having heart issues because I went to the ER for coughing up blood. The first doctor I saw suspected pulmonary embolism but it wasn’t. It was pneumonia. The doctor that discharged me put down my reason for coming in as ‘chest pain’ so now I have ‘suspected heart disease’ listed on my health insurance. What?! All of that documentation matters and getting it fixed or erased is next to impossible.

  3. I requested my records from my ob when I was pregnant with my 5th and planning a homebirth. My midwife wanted records from previous pregnancies/deliveries. And yes, they were absolutely full of errors. Or, at least, the records we could read. Some were so illegible that neither of us could decipher them.

  4. As a patient, I’ve seen so many errors that I just tell my story every time I get the chance . . . and unless I’ve really got a problem, I Stay Away From Doctors. There are good ones out there–but a patient must make up her own mind, and I often interview three docs before I let one treat me.

  5. Last year, going to the doctor(I’ve been going to her for five years and have belonged to this health care plan since 1963) for just a check-up, her nurse handed me a sheet of paper to fill out. I’m looking at the questions and they were all about depression. I ask her what the heck these were for and she said my record shows I suffer from ‘major depression.’
    I told her in no uncertain terms that I was not depressed and never have been and get that off my record. I’m still scratching my head over how that got on my records. Now my record probably shows I have ‘anger management’ problems.

  6. Our biggest problem has been records missing completely. One of the hospitals has a record of me being admitted under a certain doctor, but no other records at all. The other records have had a bunch of errors, mostly small things that don’t really matter, like Owen being our 3rd child and his weight at birth being anywhere from 7lbs 7 oz – 10lbs 13oz. I did have one troubling error with my records though. With my second son, I had been induced and the nurse sent me home without checking me for dilation even though I was having contractions. We ended up not leaving the hospital and I almost had him in the waiting room. Later, when I got the records it had my labor listed as being a completely different duration. My new practitioner kept telling me that my previous labor hadn’t gone the way I said it had because that’s not what my records said. That error seemed a little too deliberate to be a mistake to me.

  7. Every single one of our children’s birth certificates have errors on them. I have never checked our records though. I did get a bill for Taylor’s birth, I was charged for an epidural and when I called to dispute the insurance said they weren’t going to correct it. The hospital asked if I was sure I didn’t have one. Umm Yes, I would know that.

  8. I actually work in medical records. I’ve been doing medical transcription for 19 years. I would like to state that it is hard to stay focused all the time. We also have kids, parents, stress, phone calls, interruptions etc. I personally have a very low error rate and I am proud of it, but it has cost me. Medical transcriptionists are paid by the line. The more we produce the more we are paid. It’s hard to not be tempted to go fast and not carefully. Also, right now the industry is going through so many changes with voice recognition software taking over that it is very difficult to keep up with everything. Right now I’m working for one hospital, but due to it being a transitional time, I am working on 3 different computer platforms and I have to remember little discrepancies with all 3 of those. While I am concentrating on trying to remember to perform all these different operations that all the different platforms need done and trying to remember the account specifics, grammar, etc., sometimes my brain just gets too full and mistakes get made and I work at home, so if the phone rings or one of my kids interrupts, I have to really work hard to get back into the zone and make sure everything is going right with my report. Add to that the fact that the physicians are exhausted and making a lot of errors and we get blamed for not catching and correcting those errors, it is a very difficult job. (Yes, I am job hunting.)

    I would advise everyone to do as you have, request your records and read them.

      • I have been in the medical records field for 11 years and you don’t know how many errors I correct daily for physicians, even more so now with the new EMRs. It is horrid! I have been telling everyone I know for years to always request copies of your medical records at least once a year like you do with your free credit report. Make sure they are correct! Transcriptionists make far fewer mistakes than the docs do and now with the docs doing their own entering in EMRs the mistakes being made are horrific! There is no one to catch these errors anymore! These docs are already overworked and over-exhausted and now they have to input their own reports. I’ve taken it upon myself in my position at my job in medical records to go behind the docs and read all of their reports and correct them before the docs sign off on them and they get into the patient’s charts.

    • Thank you for sharing this, FatCat. I was hoping someone “in the know” would chime in. I totally get how difficult it must be to work on different computers. And voice recognition? That’s kind of scary. Someone posted on Facebook that they had “hernia surgery” transcribed as “her knee surgery”. I agree, docs are overworked and asked to see too many patients. I didn’t get into mistakes made while Apollo was in the hospital, because I wanted to focus on just the records, but it is so scary to a parent of a medically complex child. I am his best (and only) advocate, and it sometimes feels like a full-time job just keeping up on this stuff!

      • Also a long-term transcriptionist here. I’ve been doing this job for 30 years. It frightens US at times how the profession has constantly changed for the worst. Stress and haste = mistakes. Doctors make mistakes ALL the time. And usually it is us or a nurse or some ancillary standing between a medical misdiagnosis or medication error. But the demands of greed have pushed quality pretty much out of the marketplace. We are pushed ever more to pump out the words and the meanings are moot. We are under the microscope for grammar, punctuation, medical terminology, and literally being mind-readers, but not one effort is placed toward quality of our audio, instructing physicians HOW to dictate, HOW voice recognition even works, so we slave away now for literally pennies while we get marked and scrutinized to death. ALSO, YOUR records are going overseas for transcription. In other words, HIPPA is useless. Once your voice file goes into the major companies that now rule the MT field, YOUR record is being transcribed by a much lesser trained individual, who also is much lesser scrutinized. We usually have to maintain approximately 99% quality, overseas, it is bumped down into the 80s. Once it goes overseas also, there is NO protection that your record remains PRIVATE. You literally could see your records pop up on the internet w/o any recourse. Up until 4-5 years ago, when the big companies decided Voice Recognition was the wave of the future (many of us refer to it as voice WRECK hint)… The greater majority of us were self-sustaining in our pay. NOW, we generally have to work twice as hard to make half the pay. But the bottom line is no longer quality per the suits, the bean counters. Faster, more profitable for the facilities is all that matters and until we can get patients more concerned and active, it will continue to go downhill. Action and knowledge are key. Patients need to be more informed and put the facilities to the fire.

  9. I am a parent of a kid with medical issues and have felt with this – and it is very frusterating! After our last hospital stay we got discharge papers on a different child – and of course did not notice until we got home. BUT – I am also a physician assistant and work against a broken medical system. We are expected to see more and more patients in shorter amounts of time. It is becoming extremely stressful and nearly impossible to get charting done quickly and accurately. This is no excuse – but I can easily see how these mistakes happen. I think the best way to correct (kind of) the problem is to do exactly what you’re doing by reviewing your charts and correcting them when there are errors. On behalf of moms – this stinks, and on behalf of medical providers – I’m sorry.

    • I agree..the system is broken…doctors are expected to see too many patients…It’s crazy, people’s LIVES are on the line every day…

  10. I agree that doctors don’t seem to place enough importance on the accuracy of their patients records, and everything is entered on the computer now so you would think they would be more careful knowing that permanent electronic file is going to follow you everywhere.
    When my OB’s office closed they asked if I wanted my paper records and I got them for curiosity’s sake. There were errors in the written notes on all 7 of my pregnancies. Incorrect birth weights, incorrect labor duration, a note about possible diabetes when I had to repeat my glucose screen, the real reason was the lab contaminated my blood sample, no mention of my concerns about my baby’s decreased movement and slowed weight gain, instead the chart said I was induced because of post due date.
    My daughter had a dislocated elbow once and in the ER they asked about her cancer status. Apparently the bone scan she had to determine bone age when she was 7 was written down as the type of scan you get during treatment for bone cancer.
    In my own medical charts, I’ve had to inform doctors that I was already taking medication that they were about to prescribe and that another medicine had made me terribly sick the last time I took it. All of those should have been listed in my records.
    Once a vigilant nurse called to ask me if I had kidney problems, she became concerned about a prescription she was calling in when she saw that I was already taking a kidney medication. Nowhere on my chart did it say I had decreased kidney function, even though that is my only serious medical condition. If the nurse had just called in the prescription and I started taking it my kidneys could have shut down.
    And I can’t count the number of medical tests and procedures doctors have tried to repeat over the years, either because the first results weren’t in the charts or because the doctor didn’t check, maybe they don’t put much faith in the records either!

  11. We requested our son’s records from his NICU stay and it is literally a pile over a foot tall. Probably needless to say, I haven’t read them all. I have read through pieces of both of my boys’ records and remember thinking to myself “Huh, i don’t remember that”. It did make me question whether that had actually happened and nobody told me, or of it was just an error (neither are great). I work in healthcare and as things move to computerized charting, I’m not sure the errors are decreasing. When we chart it’s pretty much a generic form with drop down boxes. It would be SO easy to pick the wrong one and then your record is wrong. It saves a lot of time vs. paper charting, but not sure it’s decreasing any errors!

  12. When I was a young girl, 12 and under, there was another women with the same first and last name. My middle name was Bess, and hers was Beth. The docs always did a double take because the other women was 40, and they were always mixing up our charts.

    Once I had an obgyn tell me my chart was wrong . I smiled and assured him that was actually true and his eye brows shot up a bit. Made me feel better for going through all that child birth pain. Lol.

    Anothe obgyn asked me how I had 4 kids with only 3 live births. He was very serious. Before I answered “adoption ” he was called away for a birth. I know that one is not a chart story but it makes me laugh.

  13. Gets even worse when you have to make sure certain diagnosis are listed to ensure insurance payment. As a student my entry into the medical record is discarded but I have found some records impossible to decipher. The most noted being on rounds one day when our attending couldn’t decipher any of the notes from another service. He was extremely frustrated as it was determining management of a patient. Obviously the other team had made recommendations that no one could follow. (He called and eventually got the answers but it was such a waste of his time.). I have seen medical errors and when going through a patients’s recorded history with mom often get a laugh as she explains what the truth of the matter is. Some hospitals are now letting patients view their medical record online. I think that’s fantastic and would only help with reducing recorded errors

  14. All your medical error stories horrify me! I’ve been doing medical transcription as an employee of a world-renowned hospital for ten years; nine of those years as a float (any and all departments) and one year so far in one specific department. Thankfully we’re paid hourly, though we do have strict productivity guidelines. We also have speech recognition, so everything the physician dictates is prefilled. We just go in and edit, which for me is harder than straight-up typing as it’s much easier to miss something as I’m listening to the dictation. Plus we do work from home but have set shifts to get our work done. Since we work for the hospital though, the amount of training and oversight into our work is significant. Three solid months of training when I got the job (somebody was checking all my work), a year of monthly check-ups after that, and every-three-month check-ups after that for the duration of employment for quality control. Fail a check (less than 98%), and it’s automatic improvement plan for six months to verify no more significant errors plus the original errors are corrected after contacting the physician. If while doing a note the doctor says something that seems to be an error, we have access to the patient’s record to verify or send a question to the doctor (who can’t sign off till it’s corrected). If a transcriptionist catches an error that has been made in several notes, it gets sent to a specific person who has to contact the physician directly, verify everything, then get permission to correct all the mistakes in every note. I am so proud of all the checks and balances in our system at this specific hospital. Now, saying all that, even with all these in place (and a great many more that are too numerous to list), sometimes the doctor dictates it wrong. The transcriptionist types it exactly like the doctor states, but the physician was wrong in the first place. Case in point: I sliced my left thumb, forefinger, and middle finger pretty significantly on a rusty gutter. What did my record say? I cut my right thumb. The doctor didn’t even look at my hand. Didn’t. Even. Look. It was the nurse who cleaned and bandaged me. World-renowned hospital, remember? In my experience having only worked at this one hospital, the mistakes that are made could either be caught by the transcriptionist or the doctor. Either the doctor made the mistake by dictating incorrectly and the transcriptionist typed what he said, or the transcriptionist misheard the dictation and the doctor didn’t have time or just didn’t go back and check the document before approving it. And I’m the type of person to take it to heart if I get an email with the dreaded words “feedback” meaning a doctor caught an error I made and they were informing me. Because I know that it’s entirely likely the patient has already seen that mistake (if it is just subject/verb agreement or worse if it’s an actual medical error). So hearing your stories both fascinates and appalls me that hospitals/clinics seem not to care about the quality of their documents! Which in turn makes me wonder about their commitment to the patients themselves.

    And really, sorry for the book! I wanted to give you an idea on the non-outsourced side of transcription.

    • Yes, as someone who works overflow transcription, not for a hospital, we are also required to be 98% accurate with random checks all the time but we do not have access to the patient’s record to verify anything, so we can’t necessarily know if what the doctor says is incorrect. If we think it is an error, we can send it to our quality assurance department for verification who, in turn, confers with the hospital staff. However, if we send more than 10% of our reports to QA, our pay is docked. It’s a lose/lose sometimes.

      • As a transcriptionist of over 30 years, and a MTSO, things have drastically changed. We used to catch so many doctor errors by questioning, looking in the chart, alerting our superiors of errors on those charts, etc. There was a human who was fully trained between the spoken word and the actual chart. Later, outsourcing to India and other countries to save money caused hug errors in the charts. Then enters the “drop-down” menu of choices for the doctor to chose from, the history is copied from another report/record (so any errors are just copied and pasted) and any dictation done was limited. Now, as the majority of places have voice recognition, some with editors and others with none, as where I live, with a very large hospital, and very little to no traditional dictation, it is between an error-filled voice recognition trying to pick up strong accents and the over-worked physician. Things have been taken back to worse than when the doc scrawled nonsense on a hand-written record. There is now talk of having scribes, which are clerks, who follow the physicians into the examination room, etc., and take the notes and transcribe them. Why not just dictate, don’t outsource, and save some lives? It’s all about money and government mandates on how things will now be done better. Something has to come together, because I have never seen medical records so incorrect. They are close to useless.

  15. I’m so glad you’re such a wonderful advocate for your children! I have known that medical records are full of mistakes since I was a teenager and heard the tale, over and over, from my grandPA about how he was billed for a pap smear but he was upset because they’d never called him with the results. (He had a great sense of humor!)

  16. Ahh, the medical establishment. We’ve had similar problems. My 3yo with mild sensory issues was written in as a childhood schizophrenic. We were like, “HUH?” when a new paediatrician we started seeing brought up the schizophrenia diagnosis. Children’s handwaved it as a name mix-up, which given our last name is not unreasonable, but still. Other charming incidents include the time a doctor wrote a child’s ‘asthma’ condition as ‘arthritis,’ and the time when one child had 5 years of medical records get “lost.”

    My sister’s head nurse of a burn unit back in Philly and has unending problems with her people losing things, mixing up records, writing in completely wrong information. Takes up a huge amount of administrative time and it’s a bureaucratic nightmare. *sigh*

    You’d think that it’d just be cheaper and less stressful to train the doctors, nurses, techs and records keepers correctly in the first place and to sanction mistakes, rather than just dealing with the fallout of the mistakes and pay to cover up the employees at fault.

  17. It’s the voice recognition software. I had it for my store’s voicemail’s voice to text. It lasted a week. That beastly invention had my daughter being kidnapped and pleading for help. They even added an exclamation point after “Help!” I don’t know how anyone can decipher that garbage. It was a stupid invention.

  18. Our twins have had a few interchanged medical charting. Even all the way thru to the insurance company being billed for a service and paying for something that the other twin received.

  19. I had elevated sugars in 2011, now I don’t. I went in for a biopsy and the doctor kept saying how I was prediabetic, even putting it back into my medical records that are current. I Have the printed test results in Finnish and English and I have to carry it around to show she wasn’t paying attention at all. :/

  20. Here in NZ we get given the summary of any hospital stays on discharge, and reports from clinic appointments are always mailed to us as well, so there’s not the same risk of crazy mistakes going unnoticed. Having said that though, there are nearly always minor errors. I read through everything to make sure they are not important errors, but they are usually inconsequential.

  21. As an OR nurse(not working in the US), I know how easy it is to write the wrong or should I say not quite 100% the correct information down. Often the surgeon reads off ‘our’ paper to check his copy, but even with so many checks in place, slips up do happen. I am not sure with the whole transcribing scene goes as that is not my field, but that definitively looks scary those mistakes! We do our best in the OR to double/triple check everything, and though there are no excuses, there are some days when it is just.so.very.very.hectic and I have no idea how we accomplished all that we did, while keeping the patient safe. I also struggle sometimes with understanding sometimes the accents of the surgeons, especially when he/she is gowned up.

    I’m sorry you have such errors in your paper, and I do applaud you for being persistent and wanting the correct information.

    • Wow…so many people reading/writing/copying these papers. Sounds like a game of medical telephone. Thanks for sharing.

  22. It’s not only transcriptionists/editors being rushed and expected to work for third-world wages. Most are highly conscientious about making sure what goes in the record is 100% accurate. However, when you have no access to prior records, labs, vitals, all the information that helps determine accuracy, it becomes a matter of doing your job with both hands tied behind your back. Considering the majority of physicians are ESL, along with the fact that doctors are rushed like everyone else, and many are less than stellar dictators to begin with, and/or can’t be bothered to take the time to give the patient the attention they deserve when it comes to documenting their health care; it’s a wonder it’s not even worse than the current train wreck, created largely by the use of speech recognition. While touted to be the end all to the need for healthcare documentation specialists; VR continues to play a pivotal role in the high occurrence of errors in medical records. I have seen firsthand the critical errors VR creates and places in the document, replacing a heart medication with an antibiotic and vice versa, and the list just goes on. Not enough time in the day to cite all here, but if you care anything about your health or the medical care your family, friends, and loved ones receive, please advocate for each and every person to obtain copies of their medical records and challenge errors. It’s time someone was made accountable. The CEOs and hospital administrators are all too happy to buy into the voice recognition vendors promises. Trouble is they do not understand what goes into ensuring an accurate healthcare record, and patients are the ones paying. The doctors’ hands are largely tied, as most are now employed by the hospital systems and therefore at their mercy. Believe it or not, many facilities are placing VR drafts on the patient record without so much as even an editor viewing the draft for accuracy. I witnessed this firsthand while working for a service covering a large teaching facility of a major urban hospital system. Check your medical records regardless of how elite the facility may seem or how much you’d like to believe “they” wouldn’t let that happen. Believe me, it is happening, and you should be very wary of trusting anyone but yourself to ensure the accuracy of your personal healthcare records. http://www.yourrecordspeaks.org

    • Freida- thanks for your comment. I’m not sure where your statement “the majority of physicians are ESL” came from from or how accurate that statement is. I *will* say that all of Apollo’s doctors (and the ones referred to in this post) are native English speakers. And I agree, I am very dubious about the idea of voice recognition being used for medical records…Our local hospital has “scribes” that follow the doctors around, but this hasn’t prevented the errors I’ve mentioned either…

      • She is correct. Scribes are an old but new way of doing things, replacing the seasoned, educated, and experienced MT due to massive frustration with the EMRs and time consuming nature of that; MTs whom are fleeing en mass due to the horrendous working conditions and low wages now offered as “industry standard.” Try thinking of it this way; if VR was all it was cracked up to be and there was no need for a seasoned editor, why would you need a scribe to begin with? It is sure a lot quicker to speak it than type it or point and click.

        The scribes are often medical students doing internships for minimum wage or harried nurses/PA-As doing it for the doctors in between trying to actually hands on take care of a patient between call buttons and Code Blues. I have been an MT for 18+ years. Even in the good old USA there are serious regional accents, a warp speed doctor, and forget local slang. Yes, most are ESL especially now as what happens is the outsource vendor takes the easy English speaking doctors and offshore them to a foreign country where the draft VR report is edited for ½ a cent or less a line; this is a living wage for them, but try living on that here. I would do it for that if my rent/mortgage was only 100 a month too, but I do not live in the Philippines or India.

        The US MT is stuck with all the garbage that VR simply cannot fathom. Some doctors just should never, ever be allowed to use VR; they simply don’t get it, have too thick an accent, too many quirks, and jump around too much, etc. An MT could do this in a heart beat straight typing, but it is no longer about that. It is about teaching the VR and lining corporate pockets, and yes some doctors are using VR with no editor whatsoever.

        Everyone makes mistakes, even the required 99.7% perfect MT, but when it is outsourced you are lucky if you get an email answering a question on patient’s record ever. The only thing the big “2”care about is the bottom line. There is no way to confirm questions and no access to a patient’s records to verify. In the old day’s, you could just call the doctor, clinic, or your direct supervisor, now it is grounds for termination. Most of us are “auto terminating.”

        I have a doctor that is a middle of the road guy, scattered, often hard to understand, ESL, inconsistent, question often what he was really trying to say. He actually ends sentences frequently with etc. even in a medication list or an allergy list, so what is that, etc.? Patient is allergic to etc., patient has history of etc.? How do I edit that? On VR you can’t change it to what he really means, leave it out, or the VR goes insane, and often these companies require “verbatim.”

        Although, there are less than conscientious MTs, in defense of my profession and all those dying MTs, most of us put the utmost pride in our work and patient care, safety is always first, always was, but if you can’t pay the light bill, you just don’t work. I for one never ever want my initials on a patient’s report that has any sort of error in it, life threatening or otherwise. EVER!

  23. Renee,

    Thank you for sharing your story about the error’s found in your children’s medical records. The Association for Healthcare Documentation Integrity (AHDI) applauds you for taking the steps to ensure your family’s medical records are accurate and bringing attention to this important subject that has received very little attention in the media.

    You have clearly illustrated why it’s imperative for the healthcare community to adopt standards of practice in healthcare documentation and require the workforce creating, modifying, and formatting the clinical care records to be credentialed. Furthermore, it is critical for healthcare providers to have a robust quality assurance program in place to review, correct, and provide feedback on health records. Such a program should be in place no matter who is creating the documentation or how it is being done. For example, health records can be transcribed by a medical transcriptionist from listening to dictated recordings, edited by a medical transcriptionist from dictated recordings that have gone through a speech recognition engine, created and edited by a physician using front-end speech recognition technology, or entered into an electronic health record (EHR) by the physician directly.

    In 2013, AHDI launched the Your Record Speaks campaign to bring attention to the importance of accurate health records. We encourage your readers to visit our website, http://www.yourrecordspeaks.org, to learn about their health information rights and how to obtain copies of their records; and share this with friends and family.

    Thank you again for shedding light on this important topic and the impact it has on patient care.

    Linda G. Brady, CAE
    Chief Executive Officer
    Association for Healthcare Documentation Integrity

  24. I experienced two instances of inaccuracies in my husband’s medical records and clarifying them required intervention by an attorney as we were filing disability claims. I am now a full-time medical transcriptionist and it is my goal to produce medical reports that are as complete and accurate as I can make them so other people don’t have to hire an attorney to get a correct medical record.

  25. Renee:

    I can add my 2 cents’ worth here too as a member of AHDI and having been a medical transcriptionist for (yikes) 40 years. My middle son has genetic defects including some rather severe eye anomalies that has rendered him legally blind. When he was a wee lad and I was struggling to figure out what health issues he would face lifelong and what he was actually able to see, I had a pediatrician in our hometown who had been highly recommended by the hospital I worked at. On being referred to some specialists in Seattle, I went to pick up my son’s “medical records” from this physician I had entrusted with my precious little boy’s care. What I read absolutely horrified me down to the roots of my being! I had never seen so many mistakes and such flagrant misinformation in my life. I was so angry that I quit the practice that very day, after having a heated “heart to heart” discussion with this physician who I knew very well.

    He told me it was “no big deal” and that he was trying to “save money” by having someone inexperienced typing up his chart notes. I was staring at him with my mouth gaping open like a carp and said on more than one occasion – would you like YOUR children’s health records to look like this or have errors like this? He actually had the good sense to open and close his mouth – and then blushed fiercely. I stalked out and promptly found another physician for my son – although I still had to take the horrid records with me to his upcoming appointments.

    I have made it a practice since and informed every friend and family member I possibly can of the importance of getting their records or those records for those who can’t do it for themselves – and to CHECK THEM often. Especially today in this “electronic wonder age” where mistakes like this are not supposed to happen – guess what – they still do. The danger today is that if a medication is listed incorrectly in one record, it usually is perpetuated to at least 5 other records and on into infinity. These kinds of errors can result in not only misinformation – they can result in death or serious harm to patients.

    I applaud your courage in bringing this to people’s attention – bless you and your son. For those of us working diligently to preserve the integrity of the INDIVIDUAL medical record (which means each and every page that speaks of someone’s history) – you are the voice of wisdom in a potentially volatile nationwide disaster. What people do not know is in their record can harm and can kill them. The more attention we get to this issue, the safer our healthcare will be.

    Audrey Kirchner, CHDS
    Instructor in Medical Transcription
    MTSO owner

  26. As an MT of almost 30 years for acute care facilities I would also mention that something else to take into account is that it if the information in the report is incorrect and is not corrected by the institution/doctor office in a timely fashion, then the coding for payment is incorrect as well, which means your insurance (or you, if uninsured) is potentially being over-billed or under-billed for all that occurred during each specific medical encounter, either of which can end up being a nightmare to straighten out for either the insurance company or yourself, and, if it does get corrected after insurance has already paid you could even find yourself being presented with bills that would reflect higher/or lower costs well after the fact.

  27. I work as a medical transcriptionist and type what doctors dictate all day long. Every day in my mind I question whether the information is accurate or not, and sometimes it is blatantly incorrect. When possible, I attach a note to question a medication dosage or something else that doesn’t make sense to me and hope that someone will see it. Unfortunately, when we are hired as transcriptionists we have to type verbatim what the doctor says and are not allowed to correct things (after all we are only little peon transcriptioninsts and what could we possibly know?)….I type for doctors all day long who are joking around with other doctors while they dictate, are eating their lunch while dictating, are in the car going somewhere, are at the racetrack, on an airplane, or at home with the kids yelling in the background and the dogs barking…. Tell me they are paying attention to what they are saying and looking at with all this going on around them….It’s impossible… It is sad but unfortunately it is reality of our medical field in this country. I just started a new job and I am typing notes from hospitals in the UK and Ireland. I don’t find all these distractions going on when I type for these doctors….. I truly believe a big part of it is our lifestyle in this country and what we deem as acceptable behavior in the work place…… Reading this post makes me sad….

    • Wow…that sounds like a lack or professionalism. Maybe if doctors had fewer patients, they wouldn’t be so rushed. Thanks for sharing.

  28. As a medical transcriptionist with nearly 20 years in the industry, I can give you my opinion of why so many errors are made and allowed to slip through: Off shoring dictation to India and the Philippines, and the utilizing of voice recognition. Having proofed reports typed by transcriptionists in the Philippines and India, I honestly believe that they do not have, at best, a tenuous grasp on the English language and grammar, medical terminology, and basic human anatomy. The errors caught by voice recognition are even worse. Unless a person has been educated and trained in this profession, medical transcription, they are not qualified to listen to, decipher, and transcribe medical dictation. No machine can fully understand the nuances of the human voice nor can a machine differentiate between, for example, “course, coarse” or “plural, pleural.”

    If you want someone to blame, blame big business and lazy medical professionals. As a professional transcriptionist, I put quality and patient care far before anything else and would never have allowed a finished document to leave my hand without first being sure that no errors were present and that what I was typing, I understood, and it all made sense.

    As medical transcription is a dying field, as more and more physicians and hospitals are either offshoring work or turning to voice recognition, expect the errors to increase and greatly impact patient care. Despite the reasoning behind these practices, to save money, can anyone honestly say that money has actually been saved by utilizing offshore transcriptionists or voice recognition? Sure, big companies won’t have to pay a real person to produce quality medical reports (unless it is the peanuts that transcriptionists in this country are now being paid and trust me, it’s well below minimum wage) but then how much will have to be paid in wrongful death lawsuits?

    The solution to these errors is to bring back traditional medical transcription.

    • Medical transcription isn’t the only thing they’re not qualified to decipher. I have some messages saved from the week I had it before I let it go. Mind you, I have a jewelry store. It shouldn’t be that hard. Here is one of the messages that I had saved which was from a customer. This is copied and pasted exactly like what was sent to me, as I also received copies in email for back up. “Here son said that you want to writing. So, I was going to expect so I kind of went down first train everything looking for and I’m on way into expect cousin you know to maybe one Red Hawk, Alright. It’s, 104, and I’m just gonna go. Bye.” The one where they had my daughter being kidnapped was even more clear than this one was.

  29. I have found exactly the same. It all comes down to money. I honestly believe that most medical professionals in this country care very little for the patients entrusted to their care. I have actually heard contempt in a physician’s voice along with dictation and it is sickening.

  30. I also have been a MT for 25 years. I used to enjoy my job. Now these greedy MT companies are using editing instead of straight transcription. Editing takes just as much time to correctly review a medical record BUT these companies pay us half the amount. I make 4 cents a line. You expect me to work twice as long to make a buck? I don’t think so.

    Also add in that a huge majority of US medical records are edited overseas. Yep, that’s right. And a lot of physicians and hospitals have no idea that’s where they’re going.

    This is a dead field. Always check your medical records because surely there will be errors. MTs just don’t care anymore.

  31. Just thought of another medical records mistake that happened to me…. I was in and out of the hospital a lot with my second pregnancy (which ended in a miscarriage at 16 weeks) and one time when I was in there the doctor came in and said something about one of my problems having to do with me having chlamydia. I said WHAT? No one ever said anything to me about chlamydia. And in the back of my mind I was wondering if I knew any good divorce lawyers because I knew I didn’t have chlamydia when I got married! The doctor stammered around a bit and then left the room. I quizzed every single nurse and probably even a couple of cleaning ladies about it for the rest of my stay and none of them knew what he was talking about. I’m assuming he had the wrong charts in his hand when he came in, or he was mixing me up with the last patient he’d seen, or something, but it really threw me for a loop!

  32. I totally agree. Someone else’s nuclear medicine study was attached to my chart. My very gifted doctor was as concerned about the patient whose chart received the “normal ” report as she was that an abnormal report that was attached to my chart. With voice recognition and unqualified people now doing quality checks, I quarantee there are errors in your chart that could cost you your life. My career? Medical transcriptionist … replaced by voice recognition.

  33. As a medical transcriptionist of 48 years, currently doing quality assurance of medical reports, I can safely say that the errors you are seeing are multifactorial caused by voice recognition programs with or without an editor to follow up on the accuracy, some are physician errors, some are transcriptionist errors. As an example, when you have a rushed doctor dictating a voice recognition report which then goes to India to be edited by someone for whom English is a second language, there WILL be errors. Doing QA I see a lot of errors that are generated by the physician. They start out dictating on one patient and halfway through the report start dictating on an entirely different patient or they enter the wrong medical record number at the beginning of their dictation and it pulls the incorrect patient name and demographics into the report. The buck stops with the physician. It is his or her signature on those reports. Once upon a time physicians read their reports and hand signed them. No more. They access their reports on a computer and electronically sign them, ticking them off one by one without even looking at the reports, or at least it is the rare physician who actually looks at the report before signing it. Then there are the canned or templated reports, usually radiology and emergency room documents, where they just pull canned paragraphs into the document, a kind of one size fits all school of documentation. Having been in the field so long I feel like we crossed the point of no return years ago. This is not going to get better. It is only going to get worse. Between voice recognition and offshoring of transcription, with the ultimate goal being to dispense with medical transcriptionists altogether, I shudder to think what medical documents 10 years from now will look like. Everyone needs to be proactive about their medical reports, get them, read them, insist that the healthcare provider make corrections to errors you find.

  34. I’m another hospital medical transcriptionist – unfortunately, no longer in the field after eight years of full-time work. My company was bought out by a very large one that sends most of its work to India. The company cut our pay and cut our hours until it was no longer possible to make a living doing this job.

    It’s much cheaper for these big transcription companies to use voice recognition to cough up a document and then send the work offshore for “editing,” so that’s what they do. A great deal, right?

    Except that you have a doctor from China who barely speaks English dictating a report. That report goes through Voice Recognition, which makes all of us laugh every day with the outrageous stuff it offers up. Than that same report goes to a person in India, who also has only a fair grasp of the English language, for correcting.

    That’s where your hospital medical records are coming from. I don’t think Americans have the slightest idea that this is true.

    There are many highly trained medical transcriptionists out there, just like me, who have many years of experience and are VERY conscientious because we know how important these records are. But most of us have lost our jobs because the hospitals want to save a buck by using VR and offshore editors instead.

    It’s only a matter of time before someone dies or is seriously hurt due to errors in their medical records. Most likely, they already have, but we’ll never hear about it.

    I’m training for court reporting and broadcast captioning now. Frankly, I miss the medical work. It was nice to think that maybe I made a positive difference in someone’s life. But not any more.

  35. The wrong records problem is known as misidentification. It should be reported to your state’s department of health as a formal complaint. These errors are facilitated by the epidemic known as electronic medical records.

  36. I have been a transcriptionist for over 12 years and before that, a co-owner of a messenger service, both highly competitive and stressful fields. The competition for the business (and companies will drop you for a penny, either on a delivery charge or a line rate) has helped make us enablers. I take a lot of pride in my work, catching grammatical and medical errors, of which there is no shortage, so I really get enraged when I am told to just ‘do what they want because they pay the bills’ which frequently means misusing a word, making diseases into possessives (Parkinson’s, not Parkinson disease, for the sake of brevity?) and such. I am supposed to transcribe verbatim, but I cannot and do not. I don’t want to put my initials on a document, as someone else stated above, that contains errors, even if I have a ‘Comment Box’ to state my concerns or reasons for changing things – as if anyone reads that, anyway.

    And so we have become enablers so as not to ‘rock the boat’ and tell doctors, in essence, that they are fallible human beings! Even the most brilliant authors have editors. And I am not talking about ESL doctors, necessarily. I swear some of the native English-speaking physicians either have learning disabilities and cannot pronounce – or maybe don’t want to be bothered to try to pronounce – the simplest names of patients, or drugs, or procedures that do not come up in their particular practice or specialty. But we, of course, are there to fill in their blanks.

    I think, by silently correcting all of these things over the years, we have let ourselves become trivialized. The MT companies have a hand in this, as well, as bowing to the competition to stay in business, by allowing line rates to continue to drop so low, they are, in fact, saying that what we do is not valuable. You might as well hire chimps with really good thumbs to do our work, as we get paid probably less than the janitorial staff at this point.

    And by becoming enablers, with little voice in the matter, we have also enabled the VR software companies to market their products directly to the doctor’s egos, as they have come to think we are pretty much useless – typists! – and they have all the knowledge. Then, at that point, when they have been convinced they don’t need us anymore (because we cost too much and take too long), it is easy for them to replace us by machinery and software, and/or others whose English is as poor, in some cases, as their own.

    This obviously is not a solution to anything. Just maybe taking a different slant on just who is to blame for this mess we are in. There is enough blame to go around and some of the fingers are pointing back at us.

    As for me, I will continue not transcribing verbatim, I will do my best to explain my reasoning for changing something on a dictated report, and I will do my best, despite the lack of respect and pay, so that I can continue to be proud my initials (or my ID#) are on an as-accurate-as-possible report. I think, in the end, people will once again be valued in Medicine. I may not see it in my work/lifetime, but I have hope it will come to pass.

  37. I can totally understand how errors can occur in medical reports, charts, etc. having been a medical transcriptionist (MT) for more than 30 years and as an MT educator/instructor/trainer of future medical transcriptionists for more than 20 years. As an instructor, reviewing a student MT’s first bit of transcription, I see the mistakes made and offer correction/feedback so that the MT student learns from it. I have to say that a well-educated MT does have a lower error rate far and above someone who may not have gotten the most thorough training needed. And therein lies one of our nation’s biggest problems in who is doing our healthcare documentation, who has access, and why do they have access? We need educational/training provided to our healthcare team members, including physicians who should also take the time to read what comes back for them to sign before it is uploaded into a patient’s chart. In other words, before they allow blatant errors to perpetuate in a patient’s records. I know everyone, including physicians, are busy–should not be an excuse. I know physicians gave ti see a lot of patients–should not be an excuse. I also see that there is a need for consumers of healthcare services to be informed from visit #1 with their physician what their health status is, what medications they are taking and why, and that all this information is documented CORRECTLY in their charts. Many people (such as the originator of this article) are becoming more and more aware of their and their children’s medical information and the accuracy of that information. I congratulate you! This is great! But there are also many people who either don’t go to a doctor on a regular basis (fear), don’t understand anything if they do go, and are afraid to ask questions about their health, about their medications, (after all the doctors know everything!), and probably don’t care to know for fear of having a physician “get mad” at them for questioning anything (and then the fear the physician won’t treat them) BUT THERE ARE mistakes (put plainly, errors) in our medical records! That is why we (as a society) should be advocating for a better system of correction of health data! AND not only that, but also the protection of that data. Shouldn’t we be asking our leaders to ENFORCE the legislation that has passed through our government by becoming law–such as HIPAA? Where do healthcare entitities get the idea that it is okay to send our personal (and very private) medical information offshore? To countries, in particular, who do not have any protection of any privacy? To have our medical information transcribed by a less than minimally trained MT to do the work because it is cheap? We are on a slippery slope here and it is going to take this country getting a bit miffed (to say the least) about this situation and force some sort of change of how our healthcare records are handled, where our medical information goes, and who is handling it. As an advocate for patient safety, as an educator of MTs, and as a former MT myself, nothing short of a way to protect, correct, and education will do when it comes to our healthcare documents. Thanks for reading this post.

  38. I have been an MT for 10-plus years. I learned my craft in a vo-tech school, so yes, I’m not certified, but I also learned from my mother who was an Accredited Records Technician (back in the old days ~ I think she would be called an RHIT or RHIA now) & she taught me to be absolutely accurate, to realize that there was a live human being behind that report. In fact, she was afraid I wouldn’t make a good MT because I move from A to Z & leap over all the other letters in between, but instead during my career, I have been scolded for not producing quantity because I WILL NOT help a doctor kill or seriously a patient because of a mistake I made in transcribing the report. I take pride in the fact that any report I type is as accurate as I can possibly make it &, if I find that I have made a mistake on a previous report by a certain doctor while transcribing a different report by the same doctor, I will let my QA team know so they can catch it. I have also noticed that when I am able to look up old reports that there are mistakes made. When I have pointed them out, I’ve been told that I’m not seeing the end product or, in other words, the corrected product. I’m seeing what another MT has typed. To me, that’s scary because I’m looking at that report for a reason. I’ve always wanted to get a hold of doctors while they’re in med school & teach them how to dictate & I’ve decided if I ever have a transcription company, I’m going to try to fix it so that my employees can see the corrected product. I would also like to pay my employees more than what we’re being paid now (what do you think is a fair line count rate?). Quite frankly, I think it’s each group’s fault ~ the doctors & nurses because they have to see so many patients in a day (my mom’s cardiologist sees her for about 5 minutes & that’s it), the MT’s because we’re expected (if we want to be able to pay our bills) to do quantity rather than quality & the transcription companies (some, not all) wanting to save & make money.

    I would hope that one day all of us (doctors, nurses, transcription companies, MTs) in the medical field will wake up & see the harm that we’re doing to the patients, that we will wake up & realize that the patients we see & type are live human beings, & could be our parents, our kids, our sisters, our brothers, in short, our family members & treat them the way we would want our family members to be treated. Perhaps if & when that happens, we will put the care back in the words “healthcare field”.

  39. As a decades-long medical transcriptionist, I can tell you where a great deal of the problem arises from. Off-shoring medical records transcription and speech recognition, as well as completely degrading the highly-skilled transcriptionist field that once existed who could catch and point out these errors/question these errors of the dictating physician. This field has become unrecognizable to me at this point. Transcriptionists originally faced horrendous pay/compensation cuts, then the other issues arose (offshoring, speech recognition, etc). A computer can NEVER do what we well-trained transcriptionists can do, a non-native English speaker will have insurmountable obstacles because of a lack of basic understanding of the idiosyncracies of written and spoken English, and yet we are no longer seen as the invaluable, highly-educated, commodities and assets to the healthcare team that we once were. People should be VERY afraid.

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