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Hospital Medical Records Department - Beth

Posted: Nov 14, 2009

With HIPAA regulations tightening on who can get a carbon copy of a patient's medical record, MTs should NOT have the responsibility of sending any carbon copies at all. All carbon copy requests for a patient's records should go directly to the hospital's medical records dept for a signed release verification from the patient for that copy to be sent. Reports being sent from any outside provider without the proper signed release from the patient should be considered a severe HIPAA violation. This puts that responsbility back to the hospital/doctors where it belongs. It is totally inappropriate to ask an MT to send a carbon copy when that MT has no way of verifying a signed release from the patient for that carbon copy to be sent. It shouldn't take a rocket scientist to figure that one out... geesh.

You are ABSOLUTELY correct! - Now how do we change it?

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.

I agree - they put too much on us - especially blame

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Its crazy the way they make us responsible for demos, for verifying patients, for spelling doctors names correctly, etc. when the hospital staff has it all on hard copy right under their nose. We are forced to fly by the seat of our pants, matching patients to blank demos, then get blamed for violating HIPAA if our crystal ball is cloudy even once! Its bullshit! Every report we get with blank demos we should be able to return to the facility typed with blank demos. Every doc that feels compelled to name a physician for cc on the report should get it back blank so he can fill it in CORRECTLY himself!

I agree. Every day I struggle to choose the correct - Drs. to send CCs to, due to (sm)

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barely intelligible mumbling of the names by the dictators, an out-of-date doctor list in our software, or because at this hospital there are about a dozen Singhs and Nguyens in each department, many with the same first name. Then the MTSO gets all bent when a CC goes to the wrong guy. Well, if they think it's so darned important, then why don't they have a better system of sending out those copies than relying on the MT, and why don't the doctors act more responsibly?

All I can do is the best I can with what I've got to work with, and oftentimes that ain't much.

Sorry, don't agree at all. - MissIndigo

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Our jobs exist to meet the needs of the facilities we do work for and in future may mean increased scope of involvement in the medical record, with (perhaps) even more responsibility. Certainly not less than the paltry amount we currently shoulder for our own work alone.

In the meantime, for those who are worried, of course CYAing lies in "just following orders" set by the people who are responsible and in obtaining additional clarification as needed for murky situations, even if they do complain. You know, the usual. We can certainly handle this. It isn't much.

BTW, all the new concern over legal liability is overblown. As an appraiser I purchased E&O insurance because there was always a lot of money involved and it was my signature on the report, but employees won't end up needing it for this clerical work. That's an advantage of being an employee and low on the pole. After all, no one wants people hired to dig ditches refusing to work because a passerby might fall in.

OTOH, I was recently surprised to be threatened with firing after sending a report through with the wrong patient name. So now I'm more careful. Again, handleable.

MTSOs seem to forget that because the pay sucks so - badly, and because all they seem to(sm)

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care about is their precious TAT, that maybe their MTs are in just a wee bit of a hurry all day when they're working. If they paid us better, we could afford to slow down anddouble/triple-check every report. Most of us can't even afford to proofread anymore - we just say a silent Hail Mary and punch that "send" button as fast as we can.

You don't sound like a very good MT - lalala

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Say a Hail Mary and hit Send?
Seriously?

You should be ashamed. Work ethic like that is why doctors are looking for better and more efficient, not to mention cheaper, ways of handling medical records.

And you dont sound like you've been one for very long, - or else you would know what I mean. (sm)

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You would also be a little better at reading between the lines, and would have realized that this was more of a figure of speech, used for the purpose of illustrating the dilemma, than the actual way I transcribe. You need to stop thinking so concretely, and think a tad more in the abstract.

Why--because we get tired of UNPAID work - SM

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(which cc's, demographic, blanks, researching/looking up Dr. names is) on top of getting blame for the dictators' laziness or carelessness?

Also do not agree; I started in-hospital for years, and have found....sm - Cyndiee

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That when the dictating physician first contracts with the patient for treatment, they usually have documents to sign that the patient agrees that the attending/consulting physician may communicate with other treating physicians in the patient's best interest. It is usually spelled out pretty clearly. And this is doing the patient a favor, it expedites very important correspondence to varying physicians treating various serious aspects of this patient's care, and coordintation of care is ABSOLUTELY ESSENTIAL in most cases so every doc is on the same page, and they are working as a team to help the patient and give the best care possible. Inserting a quick cc is no big deal, and it can mean saving a life more quickly for a patient. Not much to ask, I would want it done for me, I have several fairly serious medical issues with various specialists, and every time I go to the hospital or clinic, I make sure all my docs are corresponding with each other, faster diagnoses, better care, just my own opinion.

Also do not agree - lsh

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If you don't cc then there is a delay in patient care. You wouldn't want that if that were your mother or father. It doesn't take long and with hospital websites now, you can find the correct doc in no time. Believe me, I do it.

Agree/Disgree - Beth

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Agree or disagree, come 02/2010 if an error is made in a carbon copy or demographics, the MT will be fined $100 and possibly terminated. That is HITECH HIPAA law. Whatever office has the written consent of patient is responsible for copies, how can we verify that for our own protection? The patient will be notified of all of these errors and could file potential law suits against all involved, including the MT.

please provide link verifying this law/$100 fine. - thanks. n/m

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n/m

HIPAA penalty website - Beth

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http://www.hhs.gov/news/press/2009pres/10/20091030a.html ... this website describes it and I was sent an email by my employer threatening MTs with it as well.

thanks; also, are you an IC? - n/m

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n/m

question: Do your reports automatically go out without physician approval? - Happy MT Robin

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This is the one major thing that I keep going back to. The dictator has to sign off on those reports. Someone has to sign off on those reports. Maybe it's different for other people, but I know where I've worked, even when I'm off QA and the reports are going directly to the facility, the doctor/dictator still has to review them and electronically sign them. Signing their notes/reports is actually a requirement for their medical malpractice insurance.

If, indeed, that is the case, then wouldn't the fine be on the doctor's head for not ensuring that ALL of the info was correct?

The other thing that immediately comes to mind is enforcement. Is sending a wrong cc out really going to be (a) tracked down, (b) prosecuted, or whatever terminology they use, and (c) fined? Seems to me they would deem their funds best used elsewhere. I could be wrong, though. I am about a lot of things.

The bottom line for me is, though, is that the dictator must sign their reports verifying that the information is correct. That right there takes onus off the MT and puts it right back where it's supposed to go - on the dictator.

I have not heard anything about this "fine" from my employer and quite frankly if I did and they were to somehow threaten me with it, I'd go find someone else to work for. I don't do threats.

electronic sign/IC - Beth

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No, not an IC.. QA, that's the position I lost, they still want me to be an MT for them..lol. At this place, the reports when sent from the MT computer goes directly to all docs being copied and all docs in the demographics, unless pended... I'm tempted to pend everyone requesting a cc. Just frustrated.

So do the dictators not confirm the reports at all? - Happy MT Robin

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If they do not, I can tell you with a certainty (after having gone through a medical malpractice insurance renewal interview with the psychiatrist I work for part time) that they are violating their medical malpractice insurance requirements.

Plus, the link that you provided above does not specificially say what constitutes a violation. It just says violations can be fined starting at $100. If your employer is threatening you with that, I'd sure ask them to give me more specific info on where it says that (a) sending a wrong cc is a HIPAA violation and (b) where it says the transcriptionist will be fined and not the doctor/dictator.

And we do all this for $ 0.00 ! - SM

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All work done for $ 0.00 compensation, and we're to get fined on top of it? Let them start paying us for all that unpaid work we're forced to do, THEN talk about fining the MT! Enough is enough with this exploitation!

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