Having worked in two separate doctor’s offices in the records department I am very familiar with the work load placed upon a doctor to quickly note the account after seeing a patient prior to seeing the next. His typical day might consist of seeing up to 6 patients an hour. These notes are carefully added to the permanent medical records of the patient and have a huge impact upon their long term care. What if the notes are placed in the wrong chart?
What if the notes are misinterpreted?
Doctors are known for a handwriting that is often difficult to decipher and even if that were not the case mistakes can occur when interpretations are made. I worked very carefully and thoroughly in keeping records straight and was able to assist in the understanding of patient notes on many times. For example one time I overheard the nurse calling to set up an appointment for a patient who had been diagnosed with an “E.D.” The referral was being made with a proctologist, but the patient’s problem had nothing to do with this particular area. He suffered from bulimia; an eating disorder, not from an erectile dysfunction. Because I worked on the entire file and not just one page I had more of the picture than the front desk clerk was looking at.
A better way of record keeping is now available.
Many physicians’ offices are now using modern technology and are maintaining patient files online using Electronic medical Records Software. The office I last worked in sold and closed their practice in 1999 so this came about afterwards, but I can see many advantages to this change. It truly comforts me in what I feel will be a progressive move towards better record keeping in a vital area of our life. Can you imagine if we had sent our patient on an appointment to see a doctor regarding a sexually related problem rather than his eating disorder? His insurance probably would not have paid. He would not have gotten the much needed care he needed, and he would have been embarrassed and lost confidence in our office. We would have been embarrassed too at our error.
My personal physician's office now uses Electronic Medical Records. How about yours?
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