Clinicians report missing patient information...( ssing information included laboratory r...),Health

ssing information included laboratory results (6.1 percent of all visits), letters/dictation (5.4 percent), radiology results (3.8 percent), history and physical examination (3.7 percent), and medications (3.2 percent). Missing clinical information was frequently reported to be located outside their clinical system but within the United States (52.3 percent), to be at least somewhat likely to adversely affect patients (44 percent), and to potentially result in delayed care or additional services (59.5 percent). Significant time was reportedly spent unsuccessfully searching for missing clinical information (5-10 minutes, 25.6 percent; greater than 10 minutes, 10.4 percent).

Reported missing clinical information was more likely when patients were recent immigrants (about 80 percent more likely), new patients (2.4 times more likely), or had multiple medical problems compared with no problems (2-5 problems: 87 percent more likely; more than 5 problems: 2.8 times more likely). Missing clinical information was less likely in rural practices (48 percent less likely) and when individual clinicians reported having full electronic records (60 percent less likely).

"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," the authors write.

"This is the first direct study of missing clinical information in primary care, in contrast to retrospective detection of missing information as the etiology of a medical error or adverse event. It demonstrates reports of a high frequency of missing important clinical information, with a wide array of potential impact on patient care. Additional research on missing clinical information should focus on validating clinicians' perceptions and conducting prospective studies of its actual causes and sequelae," the authors conclude.

(JAMA. 2005;293:565-571. Available post-embargo at

Contact: Tonya Ewers
303-724-1524
JAMA and Archives Journals
1-Feb-2005

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