I have worked in health carefor over 25 years, 18 of those years spent in medical Records (Health Information). Over that time span, I have seen paper charts convert to electronic charts. With addition of Dragon speak, and other voice recognition software, errors abound. It picks up any little quirk you may have, and that ends up in your dictation. If the provider pauses, or drags on certain words it ends up in dictation. A great example is one provider was referring a patient to Minneapolis Heart institute,and it was recognized as Minneapples.

Although I thought it was funny, I also wondered how unprofessional it looked to the facility who received it. In a perfect world the providers would proof each dictation before signing off, but with the amount dictation, it rarely gets done.

The ramifications of errors

Unfortunately even a small error can affect a health insurance policy or a life insurance policy. I have seen people denied insurance based on family history, often times it is incorrect. One click of the wrong key at registration and your gender is in wrong, which can affect lab values as there are different normals in many tests based on gender, insurance will kick back a claim for a Pap Smear, or prenatal care if it is incorrectly entered as a male.

This should be an easy fix, right? Yes and no. Once the gender is changed to the correct one going forward it will be changed, but the past visits, orders etc. will all have to have an addendum added, stating the gender is incorrect, and that is all that can be done to fix it.

The examples, all from my own medical chart

I am a huge proponent of getting a copy of all of your records (if you never have before) and a copy annually.

I have found many errors in my chart, some funny, some not. When I was undergoing infertility treatment, my right ovary (it was surgically removed 2 years before I started infertility treatment) would make an appearance on my ultra-sounds, sometimes it even contained follicles. It was frustrating because I was being referred to a specialist, and I didn't want any confusion.

When I was having periodic ultra-sound scans of a pelvic mass, it was stated on my ultra-sound that I was a gravida 3 (pregnant 3 times) Para 1(the number of pregnancies that reached viable gestational age) with 2 abs (spontaneous abortions--miscarriages) I have been pregnant once, with 1 live birth.

A few years ago I tripped and fell in my garage, tearing some ligaments in my ankle, guess what dragon speak changed that to? "Patient slipped and fell in her crotch," I will admit to laughing hysterically at that one, my doctor was mortified. I have seen my family history entered wrong, changing my dad's diagnosis of type 1 Diabetes to type 2, changing the cause of his death from stroke to heart attack. That is why I cannot stress enough, read your records, if you see something you don't understand or that is wrong, bring it to your medical providers attention and ask that it be fixed.

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