Medically Trained Eyes on the Chart: The Chart Always Tells the Story

Imagine this: A patient goes in for a routine outpatient procedure. Afterward, they begin bleeding internally and need a blood transfusion. Then the computer system goes down. Labs are missed. The wrong blood is given. Time passes. The patient rapidly deteriorates, becomes critically ill, and dies.

A routine procedure ended in a death, and every step along the way left a trace: the procedure note, the vital signs, the downtime forms, the labs that were ordered and missed, the transfusion record, and the nursing notes as the patient declined. The story is there. The challenge is finding it.

The chart is full of noise. In a study of more than 104 million notes, half of all text was

copied from earlier notes, rising from 33% in 2015 to 54.2% in 2020 (Steinkamp et al.,

2022). A missed lab or the wrong unit of blood can sit under pages of repetition, and a

system outage can scatter the record across paper and screen.

A medically trained reviewer knows how the pieces fit: what the labs should have

shown, which checks happen before blood is hung, and how long a bleeding patient can

safely wait. They rebuild the timeline and see exactly where it broke.

The chart always tells the story if you have someone on your team who is medically

trained to put the pieces together. At Novak LNC, that is what we do.

Reference

Steinkamp J, Kantrowitz JJ, Airan-Javia S. Prevalence and Sources of Duplicate

Information in the Electronic Medical Record. JAMA Network Open.

2022;5(9):e2233348.