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ADVANCE Perspective: HIM

Medical Record Errors

Published November 27, 2007 12:28 PM by Lisa Algeo
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With the Thanksgiving holiday last week, I completely missed this interesting story posted at Yahoo news. Maybe you did too, and I think everyone in the HIM profession should read it because you'll get a little chuckle out of it.

In a nutshell, there was some discussion on a doctor's only Web forum about errors in medical records. The patients, however, were the doctors, who were finding errors and sloppy handwriting in their own medical records.

How is the physician documentation at your facility?

posted by Lisa Algeo
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3 comments
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M.R. Coders should have the authority to not only pass on deficiencies and errors to doctors, but should be able to "change" these errors in the medical record. What I mean is that we already are "medical detectives." We see things in progress notes and charts that are sometimes overlooked by even the risk management people.
Kenneth, HIA January 4, 2008 4:36 PM
Lancaster

All of the things listed is part of the EMR and check box happy. It is very scary what can be placed on the MR with one check.
Renee , , Revnue Cycle Hospital Anylst December 27, 2007 10:35 AM
Meadville PA

Yes, after a surgical experience we obtained the chart. There were many errors! Not only that they were intentional. The surgeon compiled an entire H & P he never did. The PACU nurses charted things they did not do. VS q 5 min.! Not one was taken! Voided, ice to site...NOT!!  I was appalled. Is this what healthcare is nowadays?  How much of this is going on? We were also lied to when we ask who would be doing a personal procedure. It was an issue for us and the entire experience was extremely upsetting.
Diana December 3, 2007 3:53 PM

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