Could be a copy and paste error or perhaps a wrong template entered without personalization?  Just a couple things that could happen with computerized charts if one is too quick to click and save...and we have all probably done that...BD 

LOS ANGELES - The recent chatter on a popular social networking site dealt with a problem often overlooked in medicine: mistakes in patients' medical charts.  The twist was the patients were doctors irked to discover gaffes in their own records and sloppy note-taking among their fellow physicians.

Take Dr. Richard Botney who swapped experiences with fellow doctors. Several years ago, Botney visited a specialist to check out a bothersome lump in his cheek. He took some medicine and the problem went away.  Out of curiosity, Botney thumbed through his chart and was surprised to find a note from the doctor saying he had a stroke.  "I never even had the symptoms of a stroke. No visual changes, no weakness, no numbness, nothing," Botney, an anesthesiologist at Oregon Health & Science University, said in a telephone interview from Portland.

The online doctor's Web site, Sermo, tackled the issue of medical chart accuracy this summer.  Posting under screen names, one physician with multiple sclerosis wrote about having trouble getting an insurance company to pay for a drug after the chart incorrectly noted a diagnosis of "multiple brain tumors." Another who took over a practice had to overhaul the charting system after finding errors in the old records. A third who had had several operations was shocked to see results of physicals and other tests in the medical charts that were never performed.

Botney, the 52-year-old doctor whose records said he had a stroke, still doesn't know how the error occurred. He flagged the mistake to his specialist, but hasn't taken further action since the error hasn't affected his insurance or disability coverage.  Despite his experience, Botney said he is impressed with his current doctor, who took an hour to review his chart during the first visit.

Docs find errors in own medical charts - Yahoo! News


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