One might think that the more patient information there is the better. However, a medical record may balloon out of control and become nonfunctional. Too much of the wrong kind of information can make it impossible to find what you really need to know about a patient.
Risk factors for failure in a medical record:
(1) many serious medical problems
(2) prolonged hospital stay
(3) care provided by multiple specialists focused only on their specialty
(4) absence of a physician directing the patient's care
(5) absence of continuity in nursing care
(6) multiple transfers
(7) failure of the clerical staff to prune the chart (lack of incentive, lack of oversight, fear, poor training)
(8) no clear organization of the medical record
(9) poorly designed computer-generated reports
(10) dysfunctional hospital administration with priorities placed elsewhere
Examples of a failing medical record:
(1) a chart filled with redundant preliminary or interim laboratory reports
(2) a problem list with multiple entries for the same problem using different terms
(3) duplicate medications
The ideal medical record should allow you to know what is going on with a patient within a short period of time. If you are thoroughly confused after reviewing the chart then it has failed in its purpose.
