Incident reports in hospitals

The Sundays roll around quickly, don't they? I have a Google Alert set for my name. These blog posts get picked up almost immediately by their search engine.

I have been thinking and reading about medical records in hospitals. As you all know, the transition to electronic medical records is a big issue now and many physicians and other providers are challenged to get on board. The opportunities for people with skills related to medical records is going to increase greatly. Part of the problem is that many of the ICD-9 experts plan to retire prior to the required conversion to ICD-10 in 2012. I attended a meeting at Georgia Tech recently and learned that this transition has huge financial implications and that there are many companies in the Atlanta area hoping to earn a lot of money.

Medical coding is becoming a home-based profession. As I indicated a week ago, I see some problems with this in that people tend to learn by working in groups. Virtual groups are a possibility. Medical coding is usually taught in community colleges. It requires a knowledge of medical terms and a basic understanding of the things physicians write into medical records. While reading a book about this yesterday I learned that "incidents" in hospitals are NOT entered into patient charts. They are documented in incident reports. There is to be no evidence of the incident in the chart. This is not good. The issue is that the chart can be demanded by a court and the hospital needs the incident reports (that cannot be demanded by a court) to defend itself in court, in necessary. I see where the hospital is coming from. But if there is no reference to the incident in the chart (not even a reference to an incident report documented separately) medical errors are likely to snowball on one another. This is about transparency, but it is about more than "just" transparency. It is about the quality of care. When a provider makes a mistake the mistake needs to be in the chart. Otherwise, subsequent decisions may be made without needed understanding of what is going on with the patient. I mean, if the patient accidently received the wrong medication and is having a reaction to it, isn't it going to be difficult to make the chart make sense? In the age of evidence based care, does the omission of an important "incident" create a situation in which one omission either creates a chart that appears that care was not evidence based? If so, might the chart be at risk of becoming a work of fiction? I am not saying that this happens.

As medical coding becomes more specific with the advent of ICD-10 the omission of significant "incidents" is going to become more difficult to cover. The costs of medical care (and medical errors) are high. I think the chart should include the incidents. The problem may be that juries sometimes make excessive financial awards to patients who experienced medical errors. Maybe that should be addressed to help assure that when the court demands the chart the chart is in fact a complete record of events relevant to the case.