Another difference between the US system and UHC systems, and one linked to yours being profit-driven:
What pudytat72 and pendgwen find professionally offensive about the record is that it’s fraud (monetary issue). What I find offensive is that it’s misleading and puts the patient at risk (medical issue).
The Veterans Health Administration is, again, a government program within the Veterans Administration that serves military veterans. It is actually the largest public health program in the United States. The problem with it isn’t that it is profit-driven; the problem is that it is underfunded for the current glut of veterans who need care, frequently understaffed, and poorly managed, with fraud and malpractice being common at all levels.
Stranger
Hey, I commented on both the patient safety and fraud aspects.
For me the fraud aspect doesn’t even exist at that level. Nobody would obtain any kind of profit from claiming he’s done a physical he hasn’t. None at all. Not more money, not better reviews, not higher targets-reached, nothing. The misbehavior would be 100% medical issue, 0% fraud issue. For you, there is a patient-endangered issue but there is also an above-0 fraud issue.
And Stranger, the mindset behind how “doc reported work not done” is the mindset of people who are used to healthcare being profit-driven. That mindset is completely ingrained, it doesn’t change by how the specific system handles its paperwork and finances. It’s a country-dependent thing, not a system-dependent thing.
My claim of fraud is not the money aspect, it is the other definition: “a person intending to deceive others, typically by unjustifiably claiming or being credited with accomplishments or qualities.”
Nava is right, it is misleading and risky. I looked at past visits in a medical chart to see what might need to be followed up on. I still remember an patient visit from 30+ years ago. The hospital commander didn’t like that people were saying they could not get an appointment. So he instituted a 4 pm “walk in clinic.” This man came in requesting a refill of his Digoxin (commonly used for heart failure and irregular heart beat). “Why are you taking Digoxin?” “I don’t know” As I was going through the chart and only finding refills of Digoxin without explanation, I was looking in the lab section for Digoxin level to see if the dose is appropriate. I see a blood sugar of 271. “How is your diabetes?” “Ain’t nobody told me I was diabetic.” If the medical record isn’t complete and accurate, it is a problem.
FYI, Pudytat72 is one of 2.2 million Female veterans (10% of veteran population). My other username is Ladydock
Again, the VHA is not a for-profit institution. It does not assess doctors on the metrics related to profits (tests requested, scripts written, procedures performed, et cetera) but rather on patient throughput, e.g. attending to as many patients in a shift as possible, often pressuring doctors to exceed AMA guidelines about how many patients of which class of condition can be reasonably examined in such a period. The VHA has a pervasive problem with dishonesty at both the administrative and working level because of this focus on patient throughput over the quality of treatment, but this has nothing whatsoever to do with any profit motive; it is simply a result of a large administrative program with limited funding and an increasing base of patients in need of treatment for both physical symptoms and mental health issues.
Lying or misrepresenting an exam in medical records is not medical fraud per se, which is the promotion of unproven, questionable, or fraudulent medical practices; it is, rather, medical malpractice, e.g. the deviation from standards and practices that poses a potential or real harm to a patient through unnecessary or improperly performed procedures or a failure to determine an underlying medical issue through negligence. Malpractice can happen in any medical system, for-profit or public, and is an issue of training, ethics, and uniform enforcement of standards and procedures, which is an issue the medical profession has had globally ever since it has been considered a profession. The VHA is just particularly bad about this because of staffing problems and lack of good management.
Stranger
Other username?
My suspicion as a former healthcare IT guy is that whatever EHR that the VA uses makes them enter vitals and the other information they gathered as a “physical exam”.
As in, they have to enter a patient encounter for you, and they have to enter that vitals and EKG and whatever into the system, so maybe they just chose “physical exam” as the encounter type to get the right data entry options.
Sometimes the options in the system don’t always line up really cleanly to the real-life situation, and that’s why there are often reviews prior to billing- I know we had some exam types that didn’t necessarily spit out a physical exam CPT when completed, because they were essentially dodges for data entry, not for billing.
userID is a better term. (used on other websites to log in)
Thank you for the clarification.
I know many clinicians who want their electronic medical record (EMR) software to do things like default auto-fill physical exam sections in order to simplify charting electronically (just have it auto-fill something like “results normal”, and if there’s any section for which things are not normal, I’ll change it). And, there are some EMRs that will do this.
However, it gets awfully easy for that to turn into a situation where busy clinicians might do one or two things in a review of systems or physical exam, but leave all the other defaults checked.
I don’t know if that’s the case with the OP, but it’s one way in which electronic charting can, if implemented in certain ways, encourage inaccurate charting.
Sufferin’ Succotash!
I find it incredibly disturbing that anybody would document a physical that was not done. In addition, if you are going for a routine physical and the physician is not actually examining you then IMO he is not a good physician. I don’t expect everyone to be as thorough as I am (I consider a full physical to include a head to toe exam) but the doctor should at minimum listen to your heart and lungs, palpate your abdomen, check for enlarged lymph nodes and check your feet for swelling. I find that some of the trouble in the ER comes from the use of electronic records. I can’t tell you how many times the doctors there hit the default “normal exam” button then forget to go back and change the findings that are not normal. This leads to situations where the heart is recorded as normal ( when the patient came in for an irregular heart rhythm and the rate is 150) or the patient noted to be “alert and oriented with fluent speech) when she has been completely nonverbal and nonresponsive to verbal stimuli since her stroke more than ten years prior). Both are real examples. In the case of the OP, the ER doctor may have just hit the normal exam button. I am not saying that it was right, but I can see how it could have happened.
And now on review I see that this point was already made.
Quibbling about documentation practices in the VA healthcare system is like standing in the middle of the largest buffet in the world and complaining you are hungry. They do the most extensive, detailed documentation I have ever seen and make it easily available online - a far cry better than any other medical service I’ve participated in, including the British NHS, where our oldest daughter was born. You want to talk about a other countries’ healthcare being better than in the U.S.? What rumor mill are you subribed to getting that info? Oh right, they get filthy faciliites, endless waiting queues and all the same dumb-ass doctors and nurses as everyone else all over the world - just cheaper and crappier.
I’ve personally witnessed what appears to be this exact same scenario played out in my very own hospital room once, and partially overheard at various other places in different VA hospitals many more times. It’s just another example of crazy people doing dumb stuff because they don’t get their way. The VA does a tremendous job under very difficult conditions, overall. Anyone who is eligible for VA care and not happy with it is by definition crazy, IMHO. I can’t say enough good about the VA care I’ve received over the years, and that consensus is supported by the clientele I see and talk with whenever I go there.
But there’s always going to be a certain element of dissatisfied customers/patients in any concern, depending on how it goes with the crazy ones, VA or otherwise.
I consider the EMR to be a legal document (as it truly is). I cannot lie-on paper or in person. I know that I could be required to stand up in a “court of law” and swear that I asked the questions, recorded the answers and documented the physical exam I actually performed and the findings were what I actually found. I take that responsibility very seriously. I am sad that other medical personnel do not feel the same way.
When I was hospitalized at the VA last December (severe asthma exacerbation), I noticed a piece of paper taped to the wall. When I could finally move around easily, I looked at this paper. It was a chart for the nurses and medical assistants to initial when they came into my room. The instructions were that someone should be coming into my room every hour to see if I needed anything or had any problems. There were initials in every hour block, even though I had not seen anyone in 6 or 7 hours (except dietary bringing meals). I got a pen and wrote across the page: “THIS IS A LIE-THESE PEOPLE HAVE NOT BEEN IN MY ROOM EVERY HOUR” and signed my name and dated it.
Gatopescado Meow to you too Catfish!
BeenJammin So you think it is OK to lie? You think it would be OK for a Nuclear Technician to say that he checked "Valve #4 and said it was not leaking, when, if he had checked, he would have seen that "Valve #4 was in fact leaking and would cause the reactor to fail in 3 hours? Do you want your auto mechanic to say your brakes are normal when he has not checked them?
If someone else just looks at this medical entry, they will think I don’t have a heart problem, when I do have a heart problem. They will think my abdomen is obese, when I actually have a 22 cm X 10 cm abdominal hernia with small bowel inside of it. They will think that my reflexes are normal, when I don’t have a patellar reflex in my left knee and I have a slight foot drop and balance problems. They will not know that I have tongue fasciculations and tremors in both hands. These are not insignificant details and could impact my disability determinations and other factors.
I did not complain that I had to wait in the ER 8 hours. They gave me a heated blanket, and food/drink. I knew they were busy. They kept me informed of the situation and I told them not to worry about making me wait. I felt a bit sorry for the person that had to sit and stare at me for 8 hours (suicide precaution protocol). Yes, I have major depression and PTSD, and you can call me crazy and I won’t deny it.
But the doctors need to be held accountable for the serious false records they made.
Of course not. Nor do I believe anyone looking for discrepancies in a bedside paper record in their hospital room today could be anything other than a whiny crackpot. Room checks? Really?
I believe they’ve probably already got you pegged, so good luck with your ongoing medical care - you’re gonna need it.