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, MDJAMA. 2005;293:565-571