Good Records, Good Medicine CARROLL COUNTY

February 17, 1993

The federal government's warning to Carroll County General Hospital to improve its record-keeping practices is not a case of bureaucratic nitpicking. Maintaining accurate and up-to-date patient records is as much a part of good medicine as having properly trained physicians, nurses and technicians.

One of the first things a doctor looks at when he or she enters a patient's room is the medical chart. All sorts of important information necessary for diagnoses and treatment -- vital signs, medications and previous medical orders to name a few -- are contained in that file.

Inadequate records can lead to disaster. If medications are not properly noted, patients can be given the wrong dosage. If physical exams and patient histories are not contained in the charts, doctors can't make proper judgments and render the appropriate care.

Record-keeping mix-ups even resulted in a few patients, who required special diets, receiving meals that may have aggravated their conditions. A heart patient received meals that contained too much sodium, and a woman may have lost a substantial amount of weight during her one-month hospitalization because her meals contained 300 calories a day less than her physician ordered.

Part of the record-keeping difficulties at CCGH lies with physicians who don't make timely additions to their patients' medical charts. Using the inducement of a private office with free coffee, the hospital administration is trying to get the doctors to fill out their records before they leave the institution.

CCGH can suspend privileges for those physicians who are chronically late in maintaining their records. Hospital officials should not hesitate to resort to that extreme measure when necessary.

If the record-keeping problems are not corrected, the financial repercussions for CCGH are substantial. At risk are the reimbursement the hospital receives for Medicare patients, who occupy about half of the hospital's beds.

To its credit, the hospital administration is taking these deficiencies very seriously and taking steps to correct them. We hope the next time state health officials conduct a spot check, the hospital doesn't have trouble getting a passing mark for its record-keeping.

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