Charting diagnostic safety: exploring patient-provider discordance in medical record documentation.
The accuracy of the electronic health record (EHR) is crucial to receiving safe care. In this study, patients identified as at-risk for diagnostic errors were asked to review their most recent visit notes and indicate any diagnostic concerns. In 467 patients, 51 identified a concern, typically related to communication issues, accuracy of the clinical notes, and feeling like the clinician was not taking them seriously (e.g., wrongly attributed symptoms to weight or mental health). Physician chart reviewers identified diagnostic concerns in 31 cases, of which only 11 were also identified by patients.