Are you sure you are documenting in the right patient profile?

Right or wrong chart?

Performing a patient safety assessment at a busy physician office practice recently, I came across a documentation error that the inpatient arena has had considerable success tackling for years now, but which appears to be a commonplace occurrence for our colleagues outside the big house (meaning the hospital, of course).  The problem of entering information on the wrong patients chart (paper or electonic) has been handled in hospitals by practitioners requesting two patient identifiers and cross checking them with information on the patient’s paper or electronic chart.  Clinicians in physician offices do not appear to have embraced the practice to the same extent.During an afternoon at the unnamed physician practice, I noted that a single identifier, the date of birth, was most frequently used by support staff or nurses setting up the EHR screen prior to a physician entering the examining room. However, I noted that physicians never verified the patient’s identifying information, relying on the nurse to have the correct profile pulled up prior to his or her arrival in the room. in one instance, where two siblings had appointments at the same time and in the same room, notes for one sibling were inadvertently transcribed onto the profile of the other. It could be argued that this could be an issue in pediatric practices more than in practices dealing with adult patients, since parents often try to time appointments for siblings at the same time.

Any hospital nurse or pharmacist will tell you how easy it is to pull up the wrong patient’s profile and begin charting or entering medications therein. Even before the Joint Commission requirement to use two patient identifiers for the collection of blood and administration of medication or plasma products, astute clinicians would try to develop personal habits to limit the potential of entering information on the wrong patient profile. Some hospital pharmacists for instance will often exit a patient profile upon any interruption as it is too easy to forget to switch back to the originally opened profile after the interruption has occurred.

So, what advice can we offer physician office practices in tackling this problem, which likely occurs more often than most realize?

Firstly, physician practices should adopt a policy of verifying a patients identity using two identifiers when opening paper charts and electronic profiles. Setting the expectation with patients by placing posters in waiting areas and on exam room walls will prevent any unnecessary misunderstandings. Emphasizing that these measures ensure correct documentation that impacts patient safety and ensures insurance company’s do not reject calims will also help position the practice as a positive one.

Next, physicians as well as nurses should embrace this practice with equal vigor. Physicians should not be above following the same safety procedures that nurses and office staff use.

Finally, physician offices should ensure that safeguards are put in place that prevent more than one patient being examined or treated in an exam room at one time. Office staff concede that patient information is sometimes misplaced or charted against the wrong patient and that two patients with a concurrent appointment are often a contributing factor.

A number of links to informational and best practice references related to the issue of mixing up patient profiles can be found below.  A goal of this blog is to provide a screened reference hub for information that is valuable in the development of safe medical practices.  I would appreciate it if users provide their experiences on the subject and/or provide links to other work that has proven to be valuable in their personal research on this subject.  JH, RPh

Links and Resources:

1) Oops, sorry, wrong patient! (by ISMP), Patient Safety and Quality Healthcare

2) 8 common charting mistakes to avoid. Nurses Service Organization (AON)

3) EMR Entry Error: Not so benign (AHRQ)

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One Response to Are you sure you are documenting in the right patient profile?

  1. vora_P says:

    In my practice we always ask patients to provide DOB before documenting in their EHR.

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