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How incomplete medical records lead to misdiagnosis

Medical records are a vital tool in managing your health and helping the healthcare professionals you work with make accurate diagnoses. They let doctors know what medications you are taking, past problems and procedures, and vital data that can help them determine the right course of treatment.

So, what happens when these records are not complete? For some, it can lead to dangerous consequences. Such cases have resulted in tragic stories, including the missed diagnosis of a brain aneurysm and the permanent brain damage of a small child.

Why would medical records be incomplete?

One of the primary causes of the problem is that it can be hard for healthcare systems to reliably match the patients with their records due to the variety of ways that health data is collected and entered into the system. There are thousands of hospitals and facilities and hundreds of thousands of physicians that are all collecting data on a routine basis. Most healthcare facilities do not collect data in the same way because they each have their own technologies and unique set of processes. Because of this, it can be hard to match up with other facilities and healthcare professionals.

Some patients, with more complicated medical histories, have even taken it upon themselves to keep their own records, carting around CD-Roms with CT and MRI scans on them from practitioner to practitioner to ensure that they are receiving the proper treatment.

What is HITECH?

Health Information Technology for Economic and Clinical Health, or HITECH, was an attempt by the Obama administration to rectify the problem of incomplete medical records. Under these provisions, incentives were used in an effort to get medical facilities, healthcare clinics, and physician’s offices to digitize their medical records and create an electronic health record that will make patient records more easily accessible. While this helped a little, it did not address the patient matching problem.

Programs like these, and others that followed, created a more up-to-date electronic medical record system, but unfortunately, there was no common framework for these systems to communicate.

How could the healthcare facility get closer to 100% matching?

While a perfect matching system may never exist, there are solutions that can help improve the percentages. Facilities could use referential matching, which is a new technology that leverages the history of the demographic area of the individual. That way records can still be matched, even if there is incomplete or outdated data.

Providers that have already begun using this technology are finding it promising in many aspects, including reducing insurance claims denials related to poor patient matching. But even more importantly, the new technology is allowing providers and healthcare facilities to better diagnose and treat their patients, knowing their complete medical history before making a diagnosis.

If you have concerns that an incomplete medical record may have caused a misdiagnosis or delay in diagnosis, you may be entitled to compensation. Seek treatment as the first step, then consult with an experienced medical malpractice attorney to discuss what happened.

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