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09/17/26

Documentation-related diagnostic safety concerns in primary care: a structured medical record review of 1116 patient records.

Fernholm, Rita; Kappelin, Caroline; Nemlander, Elinor. BMJ Qual Saf.

Collection Topics
Cognition and Decision Making Culture, Work System, and Implementation Health IT
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Summary

Diagnostic safety concerns can remain hidden in routine primary care documentation. This Swedish quality improvement study combines structured medical record review and qualitative thematic analysis across 27 primary care centers to uncover latent record weaknesses that represent safety issues. Among 1,116 records, 32% contain at least one diagnostic safety concern, including undocumented reasoning, insufficient data collection, and failure to consider alternatives. The findings highlight opportunities for diagnostic reassessment, safety-netting, and learning from records.
Read the paper
Fernholm R, Kappelin C, Nemlander E. Documentation-related diagnostic safety concerns in primary care: a structured medical record review of 1116 patient records. BMJ Qual Saf. Epub 2026 Sep 17.