27 Oct Dr. Jenkins arrived in the operating room (OR) suite at 8:45 a.m. to perform surgery on an elective surgery case scheduled for 9:15 a.m
Dr. Jenkins arrived in the operating room (OR) suite at 8:45 a.m. to perform surgery on an elective surgery case scheduled for 9:15 a.m. The OR supervisor requested to speak with the surgeon to explain that the case would have to be canceled because a history and physical (H&P) report had not been completed for the patient’s record. Dr. Jenkins became visibly upset and began making accusations, saying that he had dictated the H&P three days ago and that the HIM department was at fault. The OR supervisor was already aware that her secretary had phoned Mr. Rheems, the HIM director, the day prior to inquire about the H&P report. The dictation system transcription report reflected that no dictation was available then. The OR supervisor informed Dr. Jenkins that as of yesterday afternoon there was no dictation found in the system, but that she would inquire again with the HIM department.
The transcription supervisor searched the dictation system again immediately upon receiving the call and noted the H&P report had been dictated 45 minutes earlier, at 8:15 a.m., by Dr. Jenkins, and informed the HIM director that it would be typed as soon as possible and delivered to the OR.
The transcription supervisor informed Mr. Rheems that Dr. Jenkins had done this on two other occasions during the past few months. Mr. Rheems knows the dictation system has tracking and audit capability for reports that reflect the date, time, and author of dictation, as well as identifies the date, time, and transcriber of each dictation.
1. How should Mr. Rheems respond to the OR regarding Dr. Jenkins’s H&P report?
2. Should this individual incident be taken to administrative staff?
3. If so, to whom?
4. Should this individual incident be taken to a medical staff committee?
5. If so, to which committee?
6. If not, what actions should Mr. Rheems take to prevent the recurrence of such activity against the HIM department in the future?
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