Question

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 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 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 director. The transcription supervisor searched the dictation system again immediateky 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 2 other occasions during the past few months. My 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.

1. How should Dr. Rheems respond to the OR regarding Dr. Jenkins' 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 recurrence of such activity against the HIM Department in the future.

Answer 1

1. Dr. Rheems must converse with Dr. Jenkins regarding the H & P report and convey that he has defaulted on two other occasions during the past few months. Dr. Jenkins must be aware that he cannot manipulate since 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. Also, during this discussion, Dr. Rheems may identify as to the difficulties faced, if any by Dr. Jenkins which are causing such delays. The problems therefore can be effectively resolved.
2. No, firstly there must be a one-to-one discussion between Dr. Rheems and Dr. Jenkins. If matter is resolved, then good. If not, and the issue reoccurs, then matter needs to be escalated.
3. Escalation will be done to the administrative head and the board of directors and/or council.
4. Yes, as it is pertaining to patient healthcare services which are of prime importance to the hospital.
5. The medical administration board or committee must be involved in this matter.
6. Dr. Rheems can counsel Dr. Jenkins to identify the root cause/s for the default. Give him guidance and necessary help to ensure such issues do not reoccur. Also, closely monitoring of Dr. Jenkins services will ensure that he is discouraged from committing such misunderstandings and confusions.