A patient was admitted to the hospitals ambulatory surgery unit for surgical removal of four impacted wisdom teeth.

As
required, a staff internist did a history and physical (H&P) examination prior to admission.

The dental surgeon removed the wisdom teeth and administered penicillin IM as a prophylactic. The patient had an immediate
and violent reaction. After an extensive stay in the intensive care unit (ICU), the patient was discharged.

On routine discharge analysis the Health Information Management clerk found several deficiencies requiring physician
completion. During this analysis of the record, the clerk observed that the H&P stated no know allergies. As she was filing the
ambulatory surgery record in the patients file folder, she noticed that the previous encounter had ALLERGIC TO PENICILLIN
stamped in red letters on the visit cover sheet. She placed the record in the incomplete chart area for completion.

When reanalyzing the chart a few days later, she saw that the H&P had been altered to read patient denies any drug allergies.
She took the record to the HIM director, who called the hospital attorney. The patient filed a malpractice suit a few months later.

What issues are involved and what role does HIM play in identifying errors such as this?
The big this is to not rush. Nurses auditing charts for issues. According to author Elizabeth
Shoop, its a blend of clinical, technological, and data management expertise, HIM can be a
valuable resource as hospitals establish strategies for making the transition to EHRs in a way that
enhances safety and improves care. She states its sometimes better to make it less complex.
When making a change or finding an error, identify the source. Its also better to identify the
issue and implement training if necessary. The final words in the article were, Its about the
quality of care, but also about the quality of data. I agree with that 100% - it can prevent a
terrible error or worse yet a lawsuit.

What process could be implemented to prevent this from happening again?

Having the patient wear a bracelet with the allergy warning on it

Different colored folder/chart
Have patient physically sign off (either yes or no) to any allergies, have template in place
to not allow procedure to proceed without this field entered

References
AHIMA. (2013) Integrity of the Healthcare Record: Best Practices for EHR Documentation
(2013 update) http://library.ahima.org/doc?oid=300257#.V_QUYOArLIU

Roop, Elizabeth. (March 2012) HIM Plays a Central Role in Safety, Quality
Issueshttp://www.fortherecordmag.com/archives/032612p14.shtml