The Medical Record The medical record is a legal document that has primary and s
ID: 414385 • Letter: T
Question
The Medical Record
The medical record is a legal document that has primary and secondary purposes. Primary purpose for the record is to document the patient’s health history. While secondary uses include research, billing and reimbursement. The patient has the right to view the contents within the medical record and may request to view his or her record at any time. This week, you are asked to respond to a scenario you may encounter.
Scenario:
You are a medical office specialist and have been asked to process medical record release requests for the week. As you were making copies of the medical records, you notice abbreviations written in the chart by a physician and RN that you have never seen or learned in school. You becoming increasing baffled as you continue to see these types of abbreviations. You finally ask the RN what does the abbreviations mean that were written by her and the physician? The RN explains that OULK means “one ugly looking kid;” CUEF means “clearly uneducated female” and “FAU” meant “fat and ugly.” The RN goes on to say, “no will ever know” and walks away laughing.
How would you respond to this discovery? How would you respond to the RN’s laughter? How could the R (Respect) in the "PRICE of Success" be used in this situation?
*The OULK was from an actually chart that was written by a pediatrician who had to explain what this meant during a lawsuit on the stand in front of the child’s parents*
Explanation / Answer
Once I discover that the physician is using bad language to represent the patients I cannot keep quiet and hide the incident. I would report this to the hospital management. The physician’s act is going to affect the organization’s reputation when the public will know about this. When the pediatrician have to explain the meaning of what he has written in the court the truth will come in front of everyone and the hospital would be in trouble. The incident shows that both the physician and the RN are not serious in their profession and are not loyal to their patients. The RN’s laughter also shows the same. This should not be entertained and healthcare is a very serious and respected profession.
Price of success indicates that respect and integrity are very important for leaders to achieve success. Like integrity leader’s dedication to work should command respect of others. Leaders would never ask respect and they achieve respect through their approach to the situations. The leader should treat other people with respect regardless of their role and position and always speak respectfully to others. This kind of behavior would help to increase the respect towards leader. But in this case the physician and RM has acted opposite to this and the act shows that the physician is not a good leader and does not deserve respect of others.
Related Questions
drjack9650@gmail.com
Navigate
Integrity-first tutoring: explanations and feedback only — we do not complete graded work. Learn more.