Record Keeping

Sitting on the floor beside my desk is a stack of medical records about two feet high.  I’m supposed to be reviewing them – which means reading through them and documenting the pertinent information for each record. I’ve been procrastinating this task even more than usual, not so much because the case is uninteresting or unimportant – it involves a medical malpractice case against the U.S. Naval Hospital in San Diego related to a birth defect, so it’s actual very interesting and quite important.

The main reason I’m so averse to these records is the fact that they’re all handwritten.

That’s right.  Imagine about 500 pages of chicken scratching and you’ll understand my reluctance to delve in.

Handwritten medical records are nearly extinct. Most hospital policy or policy management administrators demand policy software on board that makes medical record keeping safe, succinct, and legible. Even though these records are eight years old, I’m really surprised the hospital didn’t have digital record keeping procedures in place.

Alas, they did not, making an already onerous task even more difficult.

 

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