Friday, January 23, 2009

Censored medical records

Our hospitals don't have electronic medical records. All efforts at them stopped when the President decided to mandate them. What electronic systems we do have contain the lab reports and xray studies etc. Well, apparently we are getting a taste of what happens when the government gets involved in electronic medical records. There are now certain tests that the results are not listed in the electronic data system. They are censored. Even though only those who are actually taking care of the patient have access to the system, the government has decided that some medical tests are private and that the results should not be available in any record. One of these is HIV status. Knowing this status is very handy when trying to figure out why a chachetic patient has a pneumonia that isn't getting better or why he is having meningitis. They have even gone so far to make sure that the CD4 levels are censored so you dont even have a clue if they have HIV.

The other time they come in handy is when someone gets contaminated. We had a patient who was drunk who bit one of our nurses. Well standard protocol is to draw an HIV. Well, that information is confidential so the nurse can not find out if the patient had HIV. He/she just has to get multiple blood draws and hope that they dont get it over the next 6 months.

1 comment:

SeaSpray said...

That is just wrong!

I recall that that diagnosis wasn't supposed to be written down on the orders and we weren't to type it either. What they did is use the icd.9 codes on script or ic.

It's been so long now I am sure that has evolved.

So I guess the same goes for hepatitis?

Surely there must be a way around that???

Although...wouldn't she have to do that anyway? Can they absolutely rule it out in the patient even though they have good labs?
I thought of you tonight while watching the talking heads.

Geraldo was practically wetting his pants when he presented information on the plane that went down in the Hudson.

It turns out that plane had something wrong with the engine air intake (not sure now)twice before the ditching in the Hudson.

Same plane and as recent as 2 days prior to the accident!

I didn't think anyone would sue before and I think they should all be writing that pilot a thank you letter and more... but now...maybe some will sue.

Really tho...of they are all okay..they should let it go...although..maybe I am wrong...because that sounds like gross negligence on the part of the airlines.

There was a report written up about it with recommendations..i think on Dec 31.

Sorry - little foggy on exact facts but that is the gist of it.

i have to say... if I almost died in a plane because of a mechanical problem they were warned about...I'd be mad.

Then again... the birds.