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Medical Records--A Matter of Life and Death?

Last post 01-31-2016, 2:29 PM by Barbara O'ROURKE. 12 replies.
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  •  03-07-2015, 4:41 PM

    Medical Records--A Matter of Life and Death?

    I have been a Medical Records Scanner for a few years now.  I have in the past been told by supervisors that what I do everyday can affect the life of a patient, meaning a mistake can cost someone their life.  This type of talk bothers me a lot.  I asked one time, "How is that so"?  The supervisor then said to me: "Well, if a cardiology strip on a cardiology document is for the wrong patient, that would be harmful, if not caught"..or.."if on an Anesthesia document, if the mg. of a certain drug that was given is not seen clearly on the page due to it being cutoff at the end of a page, it could give the doctor the wrong information"...or even if we accidentally put  documents in a chart that actually belong to another patient by accident.  I think this type of logic, in my opinion, is wrong.  First and foremost, it is not OUR responsibility to give patient care..it is the PHYSICIAN'S.  Therefore, any mistake that may be on a medical record, no matter what it is, should be double checked by that doctor before doing ANY patient care.  It bothers me EXTREMELY to hear this kind of talk.  I have terrible anxiety issues already, so to have to sit there everyday and  wonder if I should be walking on eggshells everyday and wonder as I leave work if I've made some kind of mistake that may harm a patient in the future is terrible.

     

    Is any of this even really TRUE?  I think that stuff is said by supervisors just to make double sure that we are just doing our jobs correctly, which I try to do everyday anyway.  But it is a horrible thought to put into someone's head that they, like a doctor, are responsible for the life and death of a patient. 

     

    The records we scan are from past visits, so how in the world could we harm ANYONE?  Sometimes, we do get charts of a patient who is still in the hospital, but even so, I'm pretty sure there are backups of information on the patients somewhere, as well as backup of backups.  I really hope that some of you on here can maybe ease my worried mind about this issue.  I'd really appreciate it. 

  •  03-20-2015, 4:40 PM

    Re: Medical Records--A Matter of Life and Death?

    0 0 1 54 312 Crystal Clear Payments 2 1 365 14.0 Normal 0 false false false EN-US JA X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; font-family:Cambria; mso-ascii-font-family:Cambria; mso-ascii-theme-font:minor-latin; mso-hansi-font-family:Cambria; mso-hansi-theme-font:minor-latin;} I have recently started a job at a hospital in the Registration department, and understand your concerns for the seriousness involved in making a mistake.  I was also told, by my supervisor, that making a mistake can result in the hospital being sued or can cause harm to a patient.  It has certainly opened my eyes to the enormous responsibility of my position!    
  •  03-20-2015, 8:22 PM

    Re: Medical Records--A Matter of Life and Death?

    I am starting to think that it is just scare tactics to try to get the best out of an employee. I don't know, but it is NOT something I need to hear..AT ALL!
  •  04-17-2015, 8:28 PM

    Re: Medical Records--A Matter of Life and Death?

    I need more input about this subject...surely everyone here in the HIM field has an answer to this?
  •  05-10-2015, 8:41 PM

    Re: Medical Records--A Matter of Life and Death?

    I agree It's not your responsibility for patient care it's theirs and they shouldn't be putting all that pressure on you, because if anything they pressure is going to make you make a mistake. I think you should just keep doing what your doing and try not to worry about it. Do the best that you can.
  •  05-30-2015, 7:31 PM

    Re: Medical Records--A Matter of Life and Death?

    Hi.  Very thought-provoking post!   I have been in the field for many years in various roles, and I once felt exactly the same as you feel:  a ton of pressure that just made me paranoid, and I questioned the accuracy of this warning.  After all, it is ultimately the provider's responsibility to make sure the records are accurate.  However, I have seen situations in which medical errors were made based on errors in the documentation -- and though the treatment is the provider's responsibility, everyone who touches that record plays an essential part in the patient's care.  Everyone is human and errors happen, of course.  If the provider is distracted for any reason (and I am easily distracted), something crucial might be missed.  However, the only errors I have seen attributed to the HIM specialist have been due to clear breaches or very obvious incompetence.  I choose to look at it this way:  If I work hard and I'm hypervigilant -- and think of the patient at the end of that record as my mother, father, brother, sister, friend -- I have the opportunity to contribute to excellent patient care.
  •  05-31-2015, 7:10 PM

    Re: Medical Records--A Matter of Life and Death?

    Patricia English:
    Hi.  Very thought-provoking post!   I have been in the field for many years in various roles, and I once felt exactly the same as you feel:  a ton of pressure that just made me paranoid, and I questioned the accuracy of this warning.  After all, it is ultimately the provider's responsibility to make sure the records are accurate.  However, I have seen situations in which medical errors were made based on errors in the documentation -- and though the treatment is the provider's responsibility, everyone who touches that record plays an essential part in the patient's care.  Everyone is human and errors happen, of course.  If the provider is distracted for any reason (and I am easily distracted), something crucial might be missed.  However, the only errors I have seen attributed to the HIM specialist have been due to clear breaches or very obvious incompetence.  I choose to look at it this way:  If I work hard and I'm hypervigilant -- and think of the patient at the end of that record as my mother, father, brother, sister, friend -- I have the opportunity to contribute to excellent patient care.
                                                                                                                                                                                                                                                                                                                                                      

    I must say this tho.  Having discussed this with a few people who have worked in hospitals, I have come to learn that EVERYTHING is backed up in term sof patient information, including labs, allergies, medications, tests done, etc.  It makes sense because why ANYONE would rely on just one piece of documentation is beyond me.  In what I do, there are a lot of tiumes where I simply do NOT have the time to lighten or darken a document after it's scanned.  Also, I always look at the ;last eight numbers of an account and make sure that number is on everything in the chart.  I have been told that it is better to look at the whole accnt. number.  Now, my memory is good, but not THAT good.  

     

    Time is a very important consideration here.  If I am limited on time, and have to finish a certain number of charts a day, there's no way I can look at every little thing.

     

    This fear has really affected me in a bad way the past few months, but slowly I am learning, at least I THINK I am, that a lot of what is said to us is done just so we can make sure we do our best, but to say that we in the HIM field are responsible for the life and death fof someone is ultimately wrong, and I mean that in terms of making someone, like me, worry about every move I make.                                                                                                                                                                                                         

  •  05-31-2015, 8:31 PM

    Re: Medical Records--A Matter of Life and Death?

    Yes, I totally get you.  The fear can have a negative impact if we let it take hold -- and I definitely do not want to operate from the place of fear, because I am likely to make more mistakes if distracted.  I don't think that we are being groomed to be overly fearful, but just to realize that we are all a part of patient care.  You may want to talk to your manager about this.  If someone on my team had this outlook, I would definitely want to work with the person to reduce the fear, which is definitely not conducive to a positive, productive work environment.
  •  06-22-2015, 8:28 PM

    Re: Medical Records--A Matter of Life and Death?

    Interesting what you said about documentation errors in the chart. Those are done by people working the labs, doctors, radiologists, etc. As far as wjhat I do, I just prep the records, scan them, and QA them to make sure everything is in. I sometimes have to darken or lighten documents, depending how clear they need to be. Sometimes tho, dude to time limits, I can't do that. But like I said, things like that are not MY part of patient care. I didn't document anything, or treat the patient, so I am having a hard time accepting the validity of the scare tactics used at my place of work.
  •  08-18-2015, 7:05 PM

    Re: Medical Records--A Matter of Life and Death?

    Guys and Gals...I need more information on this subject...can anyone else help?
  •  08-31-2015, 7:52 PM

    Re: Medical Records--A Matter of Life and Death?

    Wow! I never really knew that Medical records jobs are very pressuring when it came to scanning records. I worked for an underwriting company and I wasn't pressured into making sure that the records had to be extremely perfect and no room for mistakes are allowed, but if I worked in a hospital, I see that it is way totally different from the other companies that have to deal with medical records and patient's health information. 
  •  09-01-2015, 2:09 PM

    Re: Medical Records--A Matter of Life and Death?

    I am a new student who is studying the field of health information management.  In every class that I have taken, an emphasis has been placed on the accuracy and legibility of the medical record.  If the document being scanned into the system is not legible and subsequently destroyed, the information may be lost forever.  The supervisor is correct to inform personnel of the importance of properly scanning the document and checking for the quality of legibility.  The information scanned serves as a record of the continuity of care provided to the patient.  All encounters with the patient, whether past or present are of equal importance and relevance to the care provided.  The document also serves as the legal record for the provider.  The supervisor does not intend to frighten personnel but rather to stress the responsibility of proper scanning.
  •  01-31-2016, 2:29 PM

    Re: Medical Records--A Matter of Life and Death?

    Hi John,

    I worked as auditor for CMS for several years.  On one assignment I was sent to the Texas OIG office to scan medical records for a doctor's office audit.  We were a team of three and we had a week to scan 300 records for the audit.  One of my partners was so fast at scanning the records I could not believe how he was doing it.  The other partner and I felt incompetent at the time.  Once I got back to the office and started to audit the records.  I found the records were scanned in upside down, backwards, and sideways.  I had to go back to Texas and "fix" all of the miss scanned records.  Because so many of the records were scanned incorrectly, we lost a lot of valuable audit time.  Your job is very important for many reasons, you are a "gatekeeper" to making sure all of the information scanned is correct.  In my experience, I found that if someone is scanning records and does not pay attention can result in undue cost for the hospital or company.  I appreciate that you are so concerned about your job.  It might be a good idea to take some HIM classes and learn from other sources why your job could be a "life or death situation" beside hearing it from your supervisor.  Knowledge is power in so many ways.  Barbara