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Originally Posted by Hopeless
This has been an interesting thread and has led me to think about medical charting in today's medical arena.
Now that electronic medical records are being required in the USA, how much of one's medical record is really accurate, depicts the truth of a patient's conditions, and how much is being charted in order to get claims paid.
My question relates to "possible" conditions that get charted that may turn out NOT to be accurate. When we go to the physician, we describe our symptoms. From them, the physician may order some tests before making a diagnosis, BUT, .... and here is what I question, in order to get the insurance company to pay for the testing, the physician must provide a diagnosis code. Let me give an example. Maybe the patient has symptoms that could be "gout". The physician orders a blood test, using the gout code, in order to justify the test. Is gout now and forever in your chart as a diagnosis even if it turns out to be something else?
In obtaining my medical records, I noticed that certain check boxes were marked off as being performed by the physician at an office visit and since I was the patient and part of the exam, I know for a fact that they were NOT performed. These check boxes were a requirement to be reimbursed by insurance and just automatically checked as done.
What good are medical records if they are NOT truly reflective of what actually transpired, what your diagnosis is AFTER test results have come back, etc. And now these records are being shared between medical personnel as an "aid" to our care??? How does an erroneous record aid patients? Seems to be that this could turn into a very detrimental situation.
I realize this is a little off topic but it is related so I thought I would put it here in this thread.
I understand the potential benefit of an electronic medical record, but I also see many problems with it. Just my opinion. Would love to hear others views on the topic.
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I personally like computer charting for many reasons. The biggest one being continuity of care. I like being able to pull up a patient's chart and get a little background and be able to pull test results. When I worked in radiology a certain blood test is needed before we can administer contrast (it's a test that lets us know if your kidneys are working properly). I could look up the result if the patient had the test run either as an outpatient or inpatient. This eliminated time spent calling a doctor's office or trying to reach the patient's floor nurse. Another radiology example is in MRI when the patient had things like a stent placed but they don't have the card that goes with it so you don't know if it is MRI safe or not. I was able to look into the patients chart for not just my hospital but for any hospital in my network and know exactly which kind of stent was placed. This allows us to determine if they can get the MRI or not and which machine they can use.
As far as the diagnosis codes (ICD 10 formerly ICD 9) go they are primarily used for insurance purposes. If the doctor were to order a test or a medication without a code the insurance company would not pay for it. My personal opinion towards insurance companies is not a very high and I feel that have no right to dictate care. To use your example of gout if the test shows you do not have gout the doctor can remove it from your current list of health issues. Sometimes there is no code available for what the doctor did so they have to enter it under a different code. Also since most tests are done to rule out a condition that condition is not listed as a diagnosis just simply a reason for a test. I am not a coder so my knowledge is limited this is just what I know from my experience and both a nurse and patient.
I’m not saying that mistakes are not made, however computerized charting does cut down on errors and makes things easier on healthcare providers. There are always going to be doctors that cheat the system in hopes of making more money. When you find things in your chart that you believe are wrong I would ask about them and see what they say.
My favorite thing about computerized charting is not having to try and read a doctor’s handwriting!
