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Posted: January 17th, 2023
How should Mr. Rheems respond to the OR regarding Dr. Jenkins’ H&P report?
HA/RP 3113
Other Majors Case Study
Due date 11:59 pm, 7/2 (Tuesday)
Interdepartmental Communications
Dr. Jenkins arrived in the Operating Room (OR) suite at 8:45 a.m. to perform surgery on a 9:15 a.m. scheduled elective surgery case. 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 obviously upset and began making accusations, saying that he dictated the H & P 3 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 on the H&P report. The dictation system transcription report reflected 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 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 over the past few months. Mr. Rheems knows the dictation system has tracking and audit capability for reports that reflects the date, time, and author of dictation, as well as identifies the date, time, and transcriber of each dictation.
Questions
How should Mr. Rheems respond to the OR regarding Dr. Jenkins’ H&P report?
Should this individual incident be taken to administrative staff? If so, to whom?
Should this individual incident be taken to a medical staff committee? If so, to which committee?
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