Reference no: EM133312353

Scenario

The HIM medical record analyst is assessing the medical record of patient Susan Smith. This patient was discharged yesterday. The analyst notes that the record does not have a history or physical document. The analyst recalls that every medical record needs a history and physical per the Joint Commission standards. In an effort to do her job, the analyst flags the record for the doctor to finish the history and physical. At this hospital, if physicians do not complete their medical records, and they subsequently become delinquent, the physicians admitting privileges are suspended.

The next day, Dr. Tired logs into his computer and sees the incomplete flag for Susan Smith's record and that the history and the physical document are missing. He knows that Susan Smith was worked up by the consulting physician after admission and he does not have notes from his own exam of the patient. Dr. Tired does not want to debate the situation, so he simply reviews the notes from the consultant and fills out the history and physical form using the information from the consulting physician's exam. Then he uploads the history and physical to Susan Smith's record so that he will not be suspended.

QUESTIONS

1. Identify and describe as many issues as you can think of with Dr. Tired's history and physical exam and the reasons why this retrospective recording of a history and physical should not have occurred.

2. If this case goes to court, will it represent care as it was truly delivered to the patient? Or, does the history and physical make a difference?

3. What might an HIM professional do to maintain ethical standards of compliance and mitigate/prevent this kind of problem from occurring?