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Clinicians report missing patient information is common

A survey of clinicians indicates that missing clinical information for patients is common and may adversely affect patients, according to a study in the February 2 issue of JAMA.

Effectively managing clinical information (patient information such as demographics, medical history, medications, test results, and family structure) is an essential part of all medical care, according to background information in the article. Unfortunately, multiple barriers complicate the collecting, synthesizing, recording, and sharing of clinical information, including privacy regulations, decentralized medical systems, inadequate interprofessional communication, the transfer of patients' care within and across care settings, and the rapid turnover of patients' insurance plans. Accordingly, physicians may not have clinical information available when it is important for a patient's care. Missing clinical information has been implicated in injurious adverse events, but has not yet been explicitly investigated in the primary care setting.

Peter C. Smith, M.D., and colleagues with the University of Colorado Health Sciences Center at Fitzsimons, Aurora, Colo., surveyed primary care clinicians about clinical information reported as missing during patient care visits. The survey was conducted at 32 primary care clinics within State Networks of Colorado Ambulatory Practices and Partners (SNOCAP), a consortium of practice-based research networks participating in the Applied Strategies for Improving Patient Safety medical error reporting study. Two hundred fifty-three clinicians were surveyed about 1,614 patient visits between May and December 2003. For every visit during 1 half-day session, each clinician completed a questionnaire about patient and visit characteristics and stated whether important clinical information had been missing.

The researchers found that clinicians reported missing clinical information in 13.6 percent of visits (nearly 1 in 7 visits); mi
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Contact: Tonya Ewers
303-724-1524
JAMA and Archives Journals
1-Feb-2005


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