Clinicians reported missing clinical information in 13.6% of visits; missing information included laboratory results (6.1% of all visits), letters/dictation (5.4%), radiology results (3.8%), history and physical examination (3.7%), and medications (3.2%). Missing clinical information was frequently reported to be located outside their clinical system but within the United States (52.3%), to be at least somewhat likely to adversely affect patients (44%), and to potentially result in delayed care or additional services (59.5%).
Missing Clinical Information During Primary Care Visits
Peter C. Smith, MD ;Rodrigo Araya-Guerra, BA ;Caroline Bublitz, MS ;Bennett Parnes, MD ;L. Miriam Dickinson, PhD ;Rebecca Van Vorst, BA ;John M. Westfall, MD, MPH ;Wilson D. Pace, MD JAMA. 2005;293:565-571
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