Clinicians report missing patient information...( nd this study along with the work of o...),Health

nd this study, along with the work of others, should engender a state of mindfulness about the frequent occurrence and importance of missing clinical information. With this cognizance, practice patterns can be modified. Physicians and their staff should screen charts prior to patients' arrival, looking for the presence of anticipated reports, letters, and dictations, and office staff should attempt to find missing data at that time. Systems should be set up within practices to track all tests until the results are in the patient's chart. These tracking systems do not have to be sophisticated or expensive -- a notebook and a copy of an order form have proved successful."

"Patient care is a team sport, and clinicians, patients, and family should be members of the team. Patients should be encouraged to keep their medication list with them at all times, and these lists should be updated at each office visit and a copy provided to the patients. Patients should also be given copies of their laboratory and radiology reports; their problem lists containing their diagnoses; and a synopsis of past operations, hospitalizations, and procedures. These can be taken to the emergency department, hospital, testing facility, and consultants. Patients can serve as an additional safety buffer in the constant struggle to manage the ever-increasing amount of clinical information necessary for the daily practice of medicine. Just as physicians strive to communicate effectively with patients, equal effort must be made to communicate effectively with all those involved in the care of patients," they conclude.

(JAMA. 2005;293:489-490. Available post-embargo at JAMA.com)

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

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