Incomplete Medical Records Form: Fill & Download for Free

Do you think the following can be automated????checking for drug interactions with incomplete medical recordschecking for drug allergies with incomplete medical recordschecking that the patient understands their drug therapymonitoring drug levels through blood tests and adjusting the doses of medicationcalculating doses for chemotherapy drugs or other drugs dosed by weight, but taking other factors into account like kidney functionchecking that the doctor didn’t prescribe too high/low of a dosechecking that the doctor prescribed the correct medication (doctors are human too and do make mistakes!)figuring out what a ‘half of a small white tablet from a foreign country’ is in the case of a drug overdosemixing IVs for the emergency room, or a ‘code blue’, or a rattlesnake bitemonitoring patient labs and changing the components of IV feedingsadvising a patient about less expensive alternativesadvising a patient what other drug options there are for a given diseaseadvising a patient why they may be experiencing a drug side effectgiving patients/doctors/nurses drug therapy adviceWhat happens when the ‘automated pharmacist’ crashes or malfunctions, or the electricity is cut off from a natural disaster???Also, some aspects of pharmacy ARE automated. There are Baker Cell dispensers to count/dispense tablets. There are many automated dispensing cabinets in hospitals like Pyxis. Some of the large mail order pharmacies are highly automated. Despite automation, for a pharmacy to legally be open, a pharmacist does need to be present.

Here’s how an ideal interaction between a doctor and a patient is supposed to go:It’s starts with a history. You sit down with the patient and LISTEN while the patient tells you why they are there. When they’re done, the doctor asks questions to extract more information from the patient.Next comes a physical exam. Take vital signs, look, listen and feel the patient to try to figure out what is wrong.After that, the doctor may order laboratory tests or radiology studies to round out the diagnosis.Which part of that script will a computer improve? Nowadays, when you go to see the doctor, he doesn’t even look at you. He’s looking at the computer and clicking boxes while the patient is talking. This detracts from the interaction between the two humans, and makes it harder to build rapport with the patient.Now, here’s where computers can be helpful. After the patient visit is over, the doctor needs to keep a record. Many of us can remember when there were paper records. It seems like the chart was never in its spot. You had to spend precious minutes finding whoever was using it, then wait till they were done before you could write your note. Trying to read doctors’ notes was like trying to decipher hieroglyphics.The problem before was that notes were illegible and incomplete. Now, the problem is that notes are too long and full of too much useless information. All of a patient’s past medical history is simply copied and pasted over and over again in each entry. Every single lab value since the Truman administration is automatically populated into every single note. Trying to find the one kernel of information for which you consulted the specialist which you know is somewhere in the note is like looking for a single passage by thumbing through the Koran.You know who medical records are designed for now? The lawyers. It’s all about documenting to make your case lawsuit proof. I’d say 90% of the information in any patient’s medical record is useless to the doctor. Furthermore, charting and navigating the awful EMR (electronic medical record) software is so daunting that hospitals have hours of mandatory training for doctors, as well as full time 24/7 IT support teams. I understand that doctors in ERs and some clinics actually have scribes now, who follow the doctors and do the charting while the doctors see patients.How is this an improvement? This is a computer program that’s so complicated that there are new jobs created just to take care of the computer part of medicine. Doesn’t make sense to me.

Question: Is it possible to appeal to have something removed from your medical records?In the US, under HIPAA, an entity that keeps medical records has to have a process to allow for amendments/corrections. That doesn’t mean that you can have something removed that is true, or even removed at all — the correction process might be to make a notation next to the the incorrect information about what is actually true.Here is a description of the HIPAA rule from HHS:If you think the information in your medical or billing record is incorrect, you can request a change, or amendment, to your record. The health care provider or health plan must respond to your request. If it created the information, it must amend inaccurate or incomplete information.If the provider or plan does not agree to your request, you have the right to submit a statement of disagreement that the provider or plan must add to your record.