Study raises doubts about accuracy of medical records

The study, published in Jama Ophthalmology, was conducted by a team from the Kellogg Eye Center and revealed inconsistencies in the details from pre-appointment surveys versus notes recorded by clinical practitioners.{{quote-A:R-W:450-I:2-Q: I think certainly the biggest takeaway is when people have presented things in different ways, they tell you different things, -WHO:Lead author Dr Maria Woodward, Assistant Professor of Ophthalmology and Visual Sciences at UM}}Lead author Dr Maria Woodward, Assistant Professor of Ophthalmology and Visual Sciences at UM, said they had found noticeable differences between the two.“I think certainly the biggest takeaway is when people have presented things in different ways, they tell you different things,” she said.The research team studied the symptoms of 162 patients from Kellogg Eye Center, where each of the participants completed a 10-point questionnaire while waiting for a doctor to attend to th.The doctors assigned to treat the patients were not informed about the surveys or that their notes taken during patient interaction would be used for comparison with any record.The study noted that only 38 of the 162 records were in ‘exact agreent’, which according to Woodward, could have implications with regard to findings based on digital medical records used in clinical practice and research.{{quote-A:L-W:450-Q: The study noted that only 38 of the 162 records were in ‘exact agreent’ }}“Many parties in healthcare use the electronic health records now and they expect the data to accurately reflect the interaction with the doctor,” she said.According to the study, 91% of patients who were worried about glare did not have that listed on their medical record, while eye redness (80%) and pain (74%) were other discordant issues.Blurry vision was the only symptom that appeared more in medical records than it did in the questionnaires.However, Woodward stressed neither party was at fault for the disparity and that the doctor-patient relationship was more nuanced than what is reflected in a medical record.