Deciphering Medical Records:

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Deciphering Medical Records
Magic or Madness
George Hrycelak, MD, FACS
Executive Director, UMANA
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If you didnt write it down It never happened.
And if it happened... Youd better have your
version written down fast, Or else the court
reporter will do it for you.
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Why keep good medical records?

• Good records allow you to
• provide proper patient care
• communicate clearly with colleagues
• refresh your unflappable memory
• leave an immutable record of transpired events
• get paid for what you do
• professionalize your approach

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What are good medical records?

• legible
• chronological
• contemporaneous
• logical
• relevant
• devoid of b.s.

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Good doctors can write poor notes. Why?

• in a hurry
• overworked
• fatigued
• never been sued
• overestimate capacity of their memory banks
• God complex I dont need to write notes

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Legal Disclaimer

• All of the following examples of medical charting
  are drawn from actual medical records. Physician
  names have intentionally been obliterated to
  spare them further ignominy. Patient names have
  been removed in order to avoid giving them ideas.
  No scenarios have been made up they didnt have
  to be. All incidents and events actually
  occurred, and a few resulted in professional
  liability actions, some successful and some
  mercifully not.

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What is the worst thing a physician can do?

• ALTER THE RECORD !
• ethical ebola virus of medical records...
• a charting Chornobyl...
• If they catch you (and they will) you will be
• SCREWED!