Inefficiency of medical reporting at ...

Inefficiency of medical reporting at Kern Valley Hospital

Posted in the Lake Isabella Forum

Barbara Lalor

Seminole, OK

#1 May 16, 2007
About six weeks ago I was a patient in the emegency room at Kern Valley Hospital for a period of about six hours. Over the years I have observed that usually when a patient leaves an emergency room, they are given a copy of what the hospital calls a "face sheet", which contains the intake information on a patient and usually, the patient is given a copy of whatever forms they sign while they are in the emergency room.

On this particular occasion, I was given nothing, even though the doctor told me I was having a heart attack and should be sent to Bakersfield. I refused and consequently, signed myself out of the emergency room against medical advice. I thought perhaps this was the reason I did not receive a copy of the pertinent records, but apparently not, since I went back out to the hospital, signed a release of information, and asked that copies of the emergency room records be mailed to me.

When I received these copies, there was no DICTATED EMERGENCY ROOM REPORT, which I did not understand. There was only a handwritten report by the examining physician, which was totally illegible, not a word on it could be deciphered. I thought perhaps I had not been specific enough when requesting copies of reports. I called medical records office and relayed my concerns about not receiving the dictated emergency room report, only to be told "We don't do that any more." I asked her to look at the handwritten report and tell me if she could read one word, to which she answered "Probably not." This is absolutely unbelieveable. Patients are being seen in the emergency room here, and there is no report generated to cover that visit.

I really would like an explanation for this. Are these doctors so busy with their three or four patients per day that they cannot take five or ten minutes to dictate a report?

Since: May 07

United States

#2 May 16, 2007
Did you ever receive a billing statement from the ER physicians and/or hospital? If so, was it accurate? How would a coder know what ICD codes to use for billing if they cannot decipher what services were rendered based on the legibility of a physician's handwriting? Was there a diagnosis listed on your records and were you able to legibly read it? I would check and double check my itemized statements from them to see if they coincide at all with what services you actually received.

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