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Medical records are filled with copy-paste errors - STAT

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I recently took care of a patient whose medical records included multiple notes about her past open-heart surgery. Only she had never undergone open-heart surgery. ADVERTISEMENT That would have been obvious if the authors had taken the time to notice that she had no scars on her chest or breastbone. She was being prepared for an invasive procedure based on this misinformation when the true facts of her condition were revealed and the procedure canceled — though by then the false information had virally propagated through the chart and into multiple notes, becoming “chart lore.” This event is hardly unique. Some years ago, a physician wrote a case study about a patient who went to the emergency room with chest pain. The patient’s chart showed a history of “PE,” so an ER physician ordered a CT scan to rule out recurrence of a “pulmonary embolism,” a blood clot in the lungs. However, the patient denied ever having had a pulmonary embolism. Further investigation showed that the letters “PE

I recently took care of a patient whose medical records included multiple notes about her past open-heart surgery. Only she had never undergone open-heart surgery. Advertisement That would have been obvious if the authors had taken the time to notice that she had no scars on her chest or breastbone. She was being prepared for an invasive procedure based on this misinformation when the true facts of her condition were revealed and the procedure canceled — though by then the false information had virally propagated through the chart and into multiple notes, becoming “chart lore.” This event is h

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