Last week, a story on electronic health records ended up in this blog – reminding me of a 2018 post I made here concerning the increasingly deleterious effect on the accuracy of medical records caused by technology and user laziness or deception that it can promote.
The 2018 post about changes in medical record-keeping can be found here. That post focused on explicit warnings placed in patient records to excuse or explain mistakes caused by transcription programs.
Portions of this chart may have been created with Dragon voice recognition software. Occasional wrong-word or “sound-alike” substitutions may have occurred due to the inherent limitations of voice recognition software. Please read the chart carefully and recognize, using context, where these substitutions have occurred. The note may not reflect the data known because of improper importation.
Obviously, mistakes (both honest and dishonest) appeared in paper charts before the advent of electronic health records. The thing is, those mistakes could be relatively easy to catch with all the simultaneous hands being on and writing in the chart. Electronic record creation leaves a patina of infallibility – as if some perfect machine was accumulating and categorizing all objective data and putting in places where it makes the most sense. That isn’t true and yet uncovering the mistakes can be treacherous. Words matter and your life can depend on them being accurate.
Last week’s post “Papers, Please” about electronic health records can be found here.
