Friday, September 12, 2008

I was a Medical Records Criminal I

People go into various specialties for various reasons. Now while almost all the potential residents who I interviewed said they had chosen anaesthesia because of their interest in physiology and pharmacology, I am sure that people my generation who largely came out of general practice what rank one factor at or near the top of their reasons:


Sadly I didn't learn and went into chronic pain management which of course means dealing with a lot of medical records and also dictating notes.

As you can guess from a previous post, I like lots of information when I see a patient (most times I would just settle for any information). When I was in general practice or working in the ER one of the things that drove me crazy was having to deal with a recently discharged patient presenting and having no discharge summary (or for that matter any records) to help figure out the usually distressed often comatose patients. Patients have certain expectations. When they present to the hospital where they were recently hospitalized they expect that the doctor will actually be able to read their chart. When of course you don't have the discharge summary and have to rely on the nurse notes and illegible progress notes, it is not their beloved doctor who is the stupid one, it is you.

With that in mind, I have always dictated my notes soon after seeing the patient. This is a practical matter. If you ask me in the evening about a patient I saw in the afternoon, I usually can't remember. And that is before I start drinking!

I work in a regionalized health authority. This has meant working in multiple hospitals. Almost 10 years ago our health authority assimilated a small suburban hospital. To make a long story short, for some reason I ended up doing fluoroscopically guided blocks in their OR. They were easy to deal with unlike the CofE where I then worked. Now when you do something in the OR you become the surgeon which means dictating an operative record. It also means signing that record. Now our health authority has always sent our dictations with "DICTATED BUT NOT READ" where the signature should be. This is a little embarassing when you make a big mistake in your dictation or when you dictate while in a bad mood and say something you really shouldn't have said. Despite that fact that your words are now widely disseminated, you are required to physically sign the report. Most medical records departments have made this easy for me by sending my dictations to me in an envelope to sign so that I don't have to go down to medical records. Anyway nowadays we have electronic signature where you read your masterpiece online, press a button and VOILA it is signed.

For some reason my otherwise flexible and helpful suburban hospital has always required me to actually go to their medical records department and sign their charts. They are for some reason which nobody can explain not part of the E-signature program even though their charts are available on-line just like every other hospital. I normally sign the charts on the days when I am out at the hospital doing procedures, which as it happens hasn't been very frequent lately so I had accumulated about 25 unsigned charts. These dictations as I mentioned had by that time been available on-line and had been mailed to the referring doctors including me.

So about a month ago, I got a phone call from the medical director's office saying that I had been kicked off staff at my little suburban hospital for not signing my charts in a timely fashion. But, because we are all part of the same happy family, this meant that I was also off staff at every hospital in the region which meant that my pain clinics were going to be cancelled. The only escape would be for me to sign my charts by midnight which meant driving 30 minutes each way to the hospital. I resigned myself to spending 60 minutes driving that evening in order to keep my priveleges. As I left the hospital though I got a phone call from the medical director's office stating that there had been a mistake by a new secretary and because I hadn't received a registered letter that I couldn't be kicked off staff but could I complete my charts by the end of the month.

Anyway about a week later, I drove out and spent about 10 minutes signing the charts.