Monday, October 6, 2008

I Was a Medical Records Criminal II

When I wrote the previous post, it brought to mind some other brushes I have had with medical records.

When I first finished my internship I went to do locums at a medium sized city in Atlantic Canada. I worked there for 10 months. Even then I was pretty compulsive about medical records and dictated all my histories and discharge summaries promptly or so I thought.

When I left I phoned up medical records, told them I was leaving town and could they get all my charts together because I wanted to finish them before I left. Like I said I was pretty conscientious then.

I worked in another community for about six months and then left the province for greener pastures. A few months after arriving in greener pastures I got a letter from the medical director stating that I was deficient in completing multiple charts and that they would be reporting me to the Medical Board unless I forthwith reported to their medical records department. I wrote a polite letter back stating that I was now on the other side of the continent, that I had actually tried to complete everything before I left, that they could have tried to contact me while I actually lived only an hour away and that despite everything if they sent me the charts I would be happy to try to complete them.

In time I received a large bundle of charts. Many of these were charts belonging to people who I had done locums for who figured it must have been me who looked after the patient in question (in most cases it wasn't). I also found out that many specialists had a little trick of transferring patients back to their family doc on the day of discharge, thus making the family doc responsible for the discharge summary. I was stung pretty badly there, worse because in most cases I never even knew the patient was in hospital and had usually never met them. I also learned for the first time that the hospital had a policy that when you assisted on a hysterectomy (which I did quite a bit) you had to write a consult agreeing that the procedure was necessary. (Imagine me as a very young GP telling the Gynecologist, "you leave that uterus in!")

Anyway I completed them as best I could and sent them back and I never heard back from the hospital again.

The first hospital I worked for as an anaesthesiologist had a very activist medical record department. We anaes don't do a lot of dictating but we do as it turns out give a lot of verbal orders which eventually have to signed. The hospital had a two week cut-off after which you were off staff and you were supposed to keep up on it which meant visiting medical records to see if you had any charts.

Now at this hospital there was a computer screen at the doctor's entrance and you were supposed to log-in every time you came in the hospital so that switchboard would know you were in the hospital. This was of minor importance when you were on call because you couldn't here overhead pages in the OR or caseroom and if switchboard didn't know you were in the hospital they wouldn't try to look for you. This on one occasion resulted in an orthopod yelling at my wife on the phone because she didn't know where I was and I had forgotten to log in. Anyway after that I always tried to log in.

One evening I was coming in to do some type of "emergency" and tried to log-in only to be told I couldn't log-in because I had been kicked off staff for not signing my verbal orders. For a second I thought, this is great, I'm going home and someone else can do this emergency. But I didn't, I worked on illegally. Actually a couple of days later, I mentioned this to the Chief of Staff who told me, "actually it didn't mean you were really off staff", which of course made me wonder what exactly it did mean and why did they even bother.

Another story someone told me around that time is kind of funny. This doctor was driving thru a rural community and was listening to the local radio station when, leading off the local news was the announcement that a doctor he knew had been suspended from staff at the local hospita. He of course contacted his colleague to find out what had happened and was told, "Oh, I just got behind on my charts, I'm not really off staff".