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Medical Forum / General / Dentistry / July 2005Dentists: What would you do?
A patient asked to read his chart while his wife was in the chair getting her teeth cleaned. My dim-witted assistant handed it to him. Under HIPAA, he's entitled to copies, but only after he's made a request in writing. She handed him the original and is reading it right now. Would any of you hand the chart to a patient prior to first reviewing it and making copies? Would you fire your assistant for doing so without getting authorization from you? I would not sweat it in the least bit. I keep my notes on the PC screen in front of the patient. They can read any of it at any time by just looking up. Everything is written as if the patient is looking over my shoulder. No secrets. Just tell the patient that your DA goofed and should have had him sign a request to see the record first, and have him sign it now. You should have forms already printed in the office ready to use. I keep mine on the hard-drive and print them when needed, or display them on a PC screen and have the patient sign a capture pad. What in the world could you possibly be afraid of the patient reading?  Signature~+--~+--~+--~+--~+-- Stephen [What's a Temporary?], D.D.S. Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... >A patient asked to read his chart while his wife was in the chair getting >her teeth cleaned. My dim-witted assistant handed it to him. [quoted text clipped - 5 lines] > and making copies? Would you fire your assistant for doing so without > getting authorization from you? >I would not sweat it in the least bit. > [quoted text clipped - 9 lines] > > What in the world could you possibly be afraid of the patient reading? Actually, nothing. I just got the chart back to review it, and saw nothing in there that I might need to "clarify" further with the patient. It's just that this particular patient has been a PITA who I referred out to a prosthodontist a year ago. He's a type-A (and beyond) personality. He refused treatment at the prosth, and still sees me for cleanings and an occasional patch job. At his last cleaning appointment, my usual hygienist was sick. We called him and told him we had a temp hygienist in, and would that be OK. He said sure. He got here, saw it was a male hygienist, and he mumbled something and left. I was afraid that the hygienist may have written something that I didn't have a chance to look at first. I guess that is a big advantage to digital records. At the end of the day, I run a report showing me everything written in any patient record by any staff person. After reviewing them, I give the receptionist permission to close out the day and "lock" those records. Prior to "locking" the records, we can edit the notes as much as we want without leaving an obvious trail. Once the end-of-day reports are run, those records can still be edited, but the original notation only gets a line through it, the edited text is printed above the original one. so anyone can still read what was altered, when and why. You, also, give rights to staff persons. You can limit what each staff person can see, what data they can enter, and what they can edit. Makes life very easy. Signature~+--~+--~+--~+--~+-- Stephen [What's a Temporary?], D.D.S. Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > >>I would not sweat it in the least bit. [quoted text clipped - 23 lines] > hygienist may have written something that I didn't have a chance to look > at first. > I guess that is a big advantage to digital records. At the end of the day, > I run a report showing me everything written in any patient record by any > staff person. After reviewing them, I give the receptionist permission to > close out the day and "lock" those records. Prior to "locking" the records, > we can edit the notes as much as we want without leaving an obvious trail. Wait a minute, is that legal to modify patient records? > Once the end-of-day reports are run, those records can still be edited, but > the original notation only gets a line through it, the edited text is > printed above the original one. so anyone can still read what was altered, > when and why. I would imagine that any form of digital records could be modified if the dentist was determined enough. That's very strange that that regulations don't reqiure a printed signed copy or something. You, also, give rights to staff persons. You can limit what > each staff person can see, what data they can enter, and what they can edit. > Makes life very easy. until the staff person hacks into your digital files and steals all the patients personal information. You may want to install a security camera near the computer screen just to make sure. The dentist is not 'modifying' records on the day of service, he is creating them. Reviewing the days notations simply allows them to be checked for accuracy and omissions. "Hmmm...that DO on Mrs. Smith was on #13, not #3" "Jimmy had a negative response to nitrous" "The decay was very close to the pulp", etc. Fawks After reviewing them, I give the receptionist permission to >>close out the day and "lock" those records. Prior to "locking" the records, >>we can edit the notes as much as we want without leaving an obvious trail. > > Wait a minute, is that legal to modify patient records? > The dentist is not 'modifying' records on the day of service, he is > creating them. Reviewing the days notations simply allows them to [quoted text clipped - 3 lines] > > Fawks It is modifying them in my book. You point to contructive and perhaps appropriate reasons the notes can be altered or modified, but I am sure that there are less virtuous uses of the editing ability. When a notation is written in the old manner, there is a record if that was subsequently altered, even if it was the same day...not so with digitized records. The ability to review and then lock gives the dentist an opportunity to change things that isn't there when records are being handwritten. I realize the records are eventually "locked", but even that brief window prior to locking leaves an opportunity for the truth to be altered. If there was involved in a situation where someone committed an act of malpractice, I'd think it likely that window of opportunity prior to locking could involve some major CYA editing. I am not implying that anyone using digital records would do this, but the opportunity is there for the less honest in our profession. T > After reviewing them, I give the receptionist permission to > >>close out the day and "lock" those records. Prior to "locking" the records, > >>we can edit the notes as much as we want without leaving an obvious trail. > > > > Wait a minute, is that legal to modify patient records? >> The dentist is not 'modifying' records on the day of service, he is >> creating them. Reviewing the days notations simply allows them to [quoted text clipped - 25 lines] > > T I write up all of my charts at the end of the day, or early the next morning. Many times I'll have the assistant jot down notes on a sticky (shade of restoration, working length for endo, heart raced from epi, etc), and then I transfer those notes to the chart later on. How is modifying electronic notes at the end of the day any different? > I write up all of my charts at the end of the day, or early the next > morning. Many times I'll have the assistant jot down notes on a sticky > (shade of restoration, working length for endo, heart raced from epi, etc), > and then I transfer those notes to the chart later on. How is modifying > electronic notes at the end of the day any different? I guess if you do it the way you do, it isn't...but what the original description said was that notes were being entered and then reviewed and edited before being finalized or locked. That would be the rough equal to someone hand writing notes in pencil as they go and then erasing what they wrote or somehow editing it in another manner. I was under the impression that any edits should be clearly marked as such. While someone wrote a very benign example of a wrong tooth # having been entered and later corrected, one could just as easily change the number of carpules of anesthetic given if a patient was later found to have had an adverse reaction. I am certainly not condemning the use or users of electronic records, I just feel they leave the window of opportunity for inappropriate records altering a bit more open then older methods. T >> I write up all of my charts at the end of the day, or early the next >> morning. Many times I'll have the assistant jot down notes on a sticky [quoted text clipped - 14 lines] > carpules of anesthetic given if a patient was later found to have had an > adverse reaction. If they're going to have an adverse reaction to the anesthetic given, they're usually going to have that reaction in the chair. I suppose that if a guy was unethical he could write down any number of carpules that he wanted at that point. If you administer 3 carpules over a 2 hour appointment (not all at once), do you write "1 carpule" each time you administer 1 carpule? Or do you write "3 carpules" at the end of the appointment? I write "admin 3 carpules". >If you administer 3 carpules over a 2 hour appointment (not all at once), do >you write "1 carpule" each time you administer 1 carpule? Or do you write "3 >carpules" at the end of the appointment? I write "admin 3 carpules". I write: Zor X 2, Mar X 1 -- W_B Take out the G'RBAGE wubbabubbazG@RBAGEyahoo.com >>If you administer 3 carpules over a 2 hour appointment (not all at once), >>do [quoted text clipped - 5 lines] > > Zor X 2, Mar X 1 You're using Zorcaine now? I was wrong when I said "Made in the USA". It's made in Canada for Kodak...but at least that's better than made in France (Septocaine). >>>If you administer 3 carpules over a 2 hour appointment (not all at once), >>>do [quoted text clipped - 9 lines] >It's made in Canada for Kodak...but at least that's better than made in >France (Septocaine). Yep, I switched to Zorcaine, no difference in efficacy noted. You are correct, better than what the frogs make. -- W_B Take out the G'RBAGE wubbabubbazG@RBAGEyahoo.com I have macros which input the information for me in full detail. 2-3 mouse clicks gets the mg of anesthetic plus the mg of vasoconstrictor entered in a precise and easily read fashion. Signature~+--~+--~+--~+--~+-- Stephen [What's a Temporary?], D.D.S. Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > >>If you administer 3 carpules over a 2 hour appointment (not all at once), [quoted text clipped - 11 lines] > Take out the G'RBAGE > wubbabubbazG@RBAGEyahoo.com > If they're going to have an adverse reaction to the anesthetic given, > they're usually going to have that reaction in the chair. I suppose that if [quoted text clipped - 4 lines] > you write "1 carpule" each time you administer 1 carpule? Or do you write "3 > carpules" at the end of the appointment? I write "admin 3 carpules". Okay, maybe my example was a poor one, but I think you get my point. If one has a chance to re-write history, or write about it sometime after the fact, there is a window of opportunity to present things differently. Once again, this is not an issue when one is honest and ethical, but I can easily envision situations where a dentist can use this extra chance to edit or re-write things to change the course of history. T > > If they're going to have an adverse reaction to the anesthetic given, > > they're usually going to have that reaction in the chair. I suppose that [quoted text clipped - 16 lines] > > T I've been watching this thread and binding my fingers to keep from adding comment. TW Why stifle yourself? IMO, crooks will be crooks, and honest people will be honest people regardless of whether a chart is paper or computerized. Fawks > I've been watching this thread and binding my fingers to keep from > adding comment. > > TW > Why stifle yourself? > [quoted text clipped - 7 lines] > > > > TW Not only do I agree ... but I have been through a personal living example that paper charts can be "altered/modified" and extra copies can be created ... and on and on. You're right, Fawks... absolutely. There is plenty that could be discussed about this particular topic. TW I cannot come in to work the next day, and remove a few pages from the chart and insert newly written ones. In a court, my data can be verified by any IT specialist that the data has not been altered after the end-of-day. Paper records require expensive and time consuming testing of ink and paper samples to verify approximate time of note creation. Signature~+--~+--~+--~+--~+-- Stephen [What's a Temporary?], D.D.S. Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > >> Why stifle yourself? [quoted text clipped - 17 lines] > > TW > I cannot come in to work the next day, and remove a few pages from the chart > and insert newly written ones. In a court, my data can be verified by any > IT specialist that the data has not been altered after the end-of-day. > Paper records require expensive and time consuming testing of ink and paper > samples to verify approximate time of note creation. I have done quite a bit of work with a old high school classmate who is now an attorney with a firm that defends dentists in malpractice cases ( a good guy!). While your comments might be true if a case reaches the point where experts are called in to analyze data, I have yet to see one where it has reached that level. Usually the records are taken at face value. If a handwritten record has erase marks, cross outs, or additions in the margins, these are readily evident to anyone looking, while something edited on a computer will be nice and clean and leave no traces of the alterations. I have seen is a TON of sloppy record keeping and often that, more than inappropriate care, is what sinks dentists in these kinds of cases. I have reviewed 100's of records from other offices helping the attorneys assess any problems the records might present and I can assure you that in many of these cases if the dentist had a chance to go back and edit his records a day, a week, or even a month (as some systems allow) later, their legal case would have been much stronger. Some may see this as good for dentistry, and while I certainly see a potential up side, I also see it as a way for someone to cover an a.s that may not deserve covering. I see your point that someone can remove pages from a paper record and write up new ones, but it is a lot easier to hit backspace and delete a few times. It also seems to me that for whatever reason people perceive things differently in the computer world. I know many people who freely download music from the internet (and not through the pay sites!), knowing they are violating the law, yet they would never walk into a store and slip a CD with that music into their pocket because that would be stealing! We all have powers that can be used for good or evil, and just because some choose evil, we shouldn't take those powers away from everyone. There are many benefits to electronic records so please don't think I am being critical of those who keep electronic records or of digital record systems in general...I am just making discussion, so don't take any personal offense. T > > I cannot come in to work the next day, and remove a few pages from the > chart > > and insert newly written ones. In a court, my data can be verified by any > > IT specialist that the data has not been altered after the end-of-day. I'm sure someone could easily write software for dentists which would alter digital records within supposedly secure software. > I have done quite a bit of work with a old high school classmate who is now > I have seen is a TON of sloppy record keeping and often that, more than > inappropriate care, is what sinks dentists in these kinds of cases. I have > reviewed 100's of records from other offices helping the attorneys assess > any problems the records might present and I can assure you that One technique to keep records is to claim them as part of your diary. Dear diary, did 2 root canals today Dear diary, had a slight mishap on #2 today... in many of > these cases if the dentist had a chance to go back and edit his records a > day, a week, or even a month (as some systems allow) later, their legal case > would have been much stronger. Some may see this as good for Easiest is to just completely remove the entire record. > > I cannot come in to work the next day, and remove a few pages from the > chart [quoted text clipped - 39 lines] > > T Over the years that I was involved in a *medical-dental* malpractice lawsuit as the plaintiff, I was deeply aware of every single word written into every single record that was brought into evidence. I worked very closely with my attorney and in many ways I was more an assistant to him than just a client. There were, IIRC, some 26 doctors involved in my care, many hospitals admissions, countless radiology reports, and many other aspects to the case that allow me to be in a position to understand exactly what Tony, T, wishes to convey to readers. As I wrote, this subject happens to be something that I find extremely interesting for various reasons. TW "The Webby" <nospamattmjiatroepidemicnospam@san.rr.com> wrote in message news:nospamattmjiatroepidemicnospam- > Over the years that I was involved in a *medical-dental* malpractice > lawsuit as the plaintiff, I was deeply aware of every single word [quoted text clipped - 9 lines] > > TW As I said, I have been in a position to review the records of many other dental offices. That alone is an eye-opening experience, but doing so has taught me that while most dentist's are ethical and honest, there are some who will use technology for evil. The same can be said of many advances in dental technology. I recall a discussion of the diagnodent a while back. Such an instrument can be a valuable tool in the diagnostic process, but can also be used to sell care of marginal necessity. We can't stand still and shy away from technology because a few use it to cheat, but the cheaters do put us in a ethical pickle don't they? T If a pen and paper guy wanted to cheat, he could save a few sheets of paper from every purchase of paper and label the paper for year of purchase. Same thing for a set of pens. Then, if he wanted to alter records, he could simply use pen and paper from the right years for the pages he wanted to alter. A good handwriting analyst *might* be able to tell the notes are recent, but the ink marker and paper markers would all be appropriate for the year they were trying to forge. Remember that ink all contain markers used to "date" the written word. Signature~+--~+--~+--~+--~+-- Stephen [What's a Temporary?], D.D.S. Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > > "The Webby" <nospamattmjiatroepidemicnospam@san.rr.com> wrote in message [quoted text clipped - 27 lines] > > T > "The Webby" <nospamattmjiatroepidemicnospam@san.rr.com> wrote in message > news:nospamattmjiatroepidemicnospam- [quoted text clipped - 24 lines] > > T They sure do. And I will say that again, "they sure do". TW Any changes after the endo-of-day are more evident than a paper record. It actually prints a line next to each entry telling the reader if the entry has been altered or not. A lot of the sloppy record keeping goes away when the office goes digital. The sloppiness is generally a result of not taking the time to do it neatly. With a digital record, all the routine stuff is entered with 2-3 mouse clicks. It only takes seconds to have precise, detailed notes which anyone can read. Signature~+--~+--~+--~+--~+-- Stephen [What's a Temporary?], D.D.S. Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > >> I cannot come in to work the next day, and remove a few pages from the [quoted text clipped - 51 lines] > > T What has happened to you that you see editing spelling mistakes, tooth numbers, missing comments, etc. at the end of the day the care was given on, as a problem? Signature~+--~+--~+--~+--~+-- Stephen [What's a Temporary?], D.D.S. Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > >> If they're going to have an adverse reaction to the anesthetic given, [quoted text clipped - 20 lines] > > T > What has happened to you that you see editing spelling mistakes, tooth > numbers, missing comments, etc. at the end of the day the care was given on, > as a problem? Perhaps my writing ability is not what I thought it was, but I think I wrote several times those are not the kind of edits I was taking issue with. Just to make it clear once again, I don't have an issue with one using the editing function in a digital record keeping system to "editing spelling mistakes, tooth numbers, missing comments, etc", but see the ability to edit notes without any trace of editing being made as having some potential downside. I know you are a proponent of electronic record keeping, and I really don't have a big issue with such systems...I was just making a point in reply to another point that stated editing records isn't modifying them. To me, anything that changes a record once it is created is "modifying" that record. It may be a totally benign reason for the edit, like the ones you describe, but it is different. That said, I am kind of insulted that you feel the need to portray me as some kind of nut who takes issue with spelling corrections in order to defend your positions on such record keeping systems...or maybe you just left out the <VBG> or smiley face? T Tony, The worst I would ever do is give you a friendly punch in the arm. I would love to buy you lunch any day. But, an argument can still be fruitful. Just harder over the internet. Let's get on the same page. You take issue with changing records with out leaving an obvious trail of the original entry and what it was changed to, when, and by whom. I say that my software does that. Dentrix and Kodak do not. That is one of my biggest arguments when someone tells me they are buying new software. I am continually amazed when other dentists don't see the importance of this issue. You can also, submit a copy of your records to the software vendor who should then verify for the court the validity of all notes. We are in agreement, aren't we???? Signature~+--~+--~+--~+--~+-- Stephen [What's a Temporary?], D.D.S. Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > >> What has happened to you that you see editing spelling mistakes, tooth [quoted text clipped - 25 lines] > > T > We are in agreement, aren't we???? I think we are! Your system sounds like a better one than most. T Think of it as writing the notes out on a loose sheet of paper until the end of the day, then handing them to your administrative assistant to type out and you sign them. Good digital records are preferred in a court-house to hand-written ones. Signature~+--~+--~+--~+--~+-- Stephen [What's a Temporary?], D.D.S. Michigan, USA .................................................... This posting is intended for informational or conversational purposes only. Always seek the opinion of a licensed dental professional before acting on the advice or opinion expressed here. Only a dentist who has examined you in person can diagnose your problems and make decisions which will affect your health. ...................... > >> I write up all of my charts at the end of the day, or early the next [quoted text clipped - 19 lines] > > T Many offices do not write the notes for the day until the last patient has been seen. That is not much different. ES software locks the notes at the end of each day. So you have until you go home to check for missing notations, proper tooth numbers and surfaces, spelling errors (not very common with spell checker), etc. Other software packages lock the notes at the end of the month (on not at all). To me, that is the big problem. If a procedure goes badly, it often takes 20 minutes to write up all the notes related to why you did not get the best result. If I use a pen and paper, I take a long time and start abbreviating, and skipping words. By the end of the note, I am lucky if I can read it myself. If I type the notes, I am done in a few minutes, no abbreviations, spell checker was used, and anyone can read it. Generally, for a case which could go to court, you realize this weeks to months later as the patient becomes upset. I personally would not want to go to court with records which the court knows I could have altered for 30 days (assuming the incident was early in the month) without leaving any trail. Once the records are locked, I can edit it, but the original note gets a line through it and is always displayed. Any printed copies of the notes or pdf file saved to disc plainly says what was altered, when and by whom. >> The dentist is not 'modifying' records on the day of service, he is >> creating them. Reviewing the days notations simply allows them to [quoted text clipped - 33 lines] >> > >> > Wait a minute, is that legal to modify patient records? realize > this weeks to months later as the patient becomes upset. I personally would > not want to go to court with records which the court knows I could have > altered for 30 days (assuming the incident was early in the month) without > leaving any trail. Actually the way drives work, normally when you delete a file it is not really deleted but the marker which points to the data on a particular area with the file on the disk is changed. The original data remains until it is written over at some random time in the future. That is why in one well known case they could take the computer of a suspect (Oliver North) and with a team of experts recreate the original files in a couple weeks. To truly delete files a software program probably has to completely rearrange or scramble all the data on the drive, so if someone really wanted to see the original notation they probably could. > A patient asked to read his chart while his wife was in the chair getting > her teeth cleaned. My dim-witted assistant handed it to him. [quoted text clipped - 5 lines] > making copies? Would you fire your assistant for doing so without getting > authorization from you? I wouldn't mind giving to a patient, but only because I learned thru the experiences of a colleague to never write anything I wouldn't mind patient reading in a chart. Friend used to make comments about patient's attitude...not a big editorial, but just things like patient seemed irritated or annoyed. No one likes reading that about themselves. T >> A patient asked to read his chart while his wife was in the chair getting >> her teeth cleaned. My dim-witted assistant handed it to him. [quoted text clipped - 14 lines] > attitude...not a big editorial, but just things like patient seemed > irritated or annoyed. No one likes reading that about themselves. I follow that same rule, too, Tony. But read my response to Dr. Steve, and you'll understand that I was concerned about what the temp hygienist may have written. > I follow that same rule, too, Tony. But read my response to Dr. Steve, and > you'll understand that I was concerned about what the temp hygienist may > have written. That is always a BIG concern. I have seen notes written in charts by front desk or assistants that could easily get someone in hot water if the wrong person read them. It is tough to impress that on people...especially ones who are there for a day or two. T > I wouldn't mind giving to a patient, but only because I learned thru the > experiences of a colleague to never write anything I wouldn't mind patient [quoted text clipped - 3 lines] > > T They had a story on the news about people who had anethesia during surgery but it didn't completely take. Apparently some patiens could hear what the surgeons and assistants would say about them. Many heard comments about body part sizes, their weight and so on. One lady was even so traumatized, they reported that she was emotionally scarred for life. I'm not saying that these stories are all bunk, but the power of 'dreams' can make many people unsure about what really transpired. Just with nitrous it is possible for patients to believe some strange stuff goes on that is nothing close to the truth. Fawks > They had a story on the news about people who had anethesia > during surgery but it didn't completely take. Apparently some patiens > could hear what the surgeons and assistants would say about > them. Many heard comments about body part sizes, their weight > and so on. One lady was even so traumatized, they reported that > she was emotionally scarred for life. How'd it work out? I bet he handed back the chart, and everything worked out OK. Please don't execute the assistant for being friendly. She could be your office's greatest PR asset. SignatureChristopher A. Young Learn more about Jesus www.lds.org www.mormons.com A patient asked to read his chart while his wife was in the chair getting her teeth cleaned. My dim-witted assistant handed it to him. Under HIPAA, he's entitled to copies, but only after he's made a request in writing. She handed him the original and is reading it right now. Would any of you hand the chart to a patient prior to first reviewing it and making copies? Would you fire your assistant for doing so without getting authorization from you? > How'd it work out? I bet he handed back the chart, and everything worked > out > OK. > > Please don't execute the assistant for being friendly. She could be your > office's greatest PR asset. He handed the chart back and everything was fine...as you stated. The assistant is now fully aware of the office policy. I made her re-read the HIPAA forms she hands out to each patient...and it states our office policy that says that any requests to review the chart must be made in writing...and that copies will be made for the patient to review. I will also let patients review the original chart *in my presence*...but no more handing original charts to patients sitting in the reception area. Very wise and temperate handling of the situation. I'm pleased things are resolved in your office. SignatureChristopher A. Young Learn more about Jesus www.lds.org www.mormons.com > How'd it work out? I bet he handed back the chart, and everything worked > out > OK. > > Please don't execute the assistant for being friendly. She could be your > office's greatest PR asset. He handed the chart back and everything was fine...as you stated. The assistant is now fully aware of the office policy. I made her re-read the HIPAA forms she hands out to each patient...and it states our office policy that says that any requests to review the chart must be made in writing...and that copies will be made for the patient to review. I will also let patients review the original chart *in my presence*...but no more handing original charts to patients sitting in the reception area. |
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