Patient records often missing, U.S. study finds

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Medical records are frequently incomplete or missing during patient visits to the doctor, posing potential danger and wasting time, a survey of physicians said on Tuesday.

One in seven patient visits was marred by missing information such as lab results, medication records and health histories, the survey of 253 Colorado physicians found.

The report by the University of Colorado Health Sciences Center in Aurora covered 1,614 patient visits during an eight-month period in 2003. 

Nearly half the incidents of missing records could have adversely affected patients’ health, the report said. Delayed care or additional services often resulted, and the doctor’s or staff’s time was wasted locating the records.

Patients with multiple health problems and immigrant patients were more likely to have records missing, the study said.

“If validated by future research, these results could have serious implications for the 220 million primary care visits that occur in the United States each year,” study author Dr. Peter Smith wrote in the Journal of the American Medical Association.

“The disjointed nature of health care in the United States” is the source of the problem, wrote Nancy Elder of the University of Cincinnati and John Hickner of the University of Chicago in an accompanying editorial.

Many physicians contract with several managed care companies that results in a complicated network of referrals for consultations and testing, they wrote. The doctor’s office may have to contact by telephone, fax, or electronically numerous laboratories, imaging facilities, consultants and hospitals to keep records up to date.

Information kept electronically reduced the incidence of problems, but was no guarantee of completeness, the editorial said. Patients should be enlisted in the effort, it said, by providing them updated lists of medications, lab and radiology reports, and records of diagnoses, surgeries and hospitalizations to bring with them when receiving care. 

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