The misinformation era: the fall of the medical record

Ann Intern Med. 1989 Mar 15;110(6):482-4. doi: 10.7326/0003-4819-110-6-482.

Abstract

Medical record information has become less reliable than ever before despite the electronic information revolution in medical care and the authority medical records have been accorded in our society. Long flawed by errors introduced by medical personnel, patients, and machines, medical records have had a further decline in credibility as a result of the loss of confidentiality and the imposition of well-meaning but unrealistic cost-control regulations on medical practice. Medical records are being distorted and fashioned to keep clinically important but sensitive personal information about patients from public view. To comply with standards of care and a reimbursement system blind to biologic diversity, medical records are being forced to address only the technical side of care. Until these deficiencies are corrected, our increasing dependence on medical records should be balanced by increasing skepticism about the value of the information they contain.

MeSH terms

  • Confidentiality
  • Cost Control / legislation & jurisprudence
  • Medical Records* / standards
  • United States