MUDVILLE, TN – Jimmy Blake, MBA, MHA, Good Samaritan’s Vice President for Administrative Affairs, speaking on condition of having his full name printed at least twice, Jimmy Blake, MBA, MHA, explained the role of the medical records censor. Their job is to ensure that medical records of patients transferred to other hospitals, especially tertiary care centers, do not contain discharge summaries, procedure reports, or other crucial documentation that might give away the patient’s diagnosis or other essentials of the treatment course. “We don’t want our referral centers to lose their edge by having it too easy,” stated Mr. Blake.
The MRC’s specific responsibilities include:
-censoring admission and discharge summaries, either wholly or in part
-plucking well-written or legible consultation notes
-duplicating random lab results and radiology reports, preferably with the pages out of order
-redacting lab results or reports related to the transfer diagnosis, such as pathology reports or cardiac catheterization reports
-providing copies of the medication administration record (MAR) in triplicate
-faithfully providing all medication reconciliation documentation
-faithful reproduction of all nursing notes
-most importantly, preventing doctors on the receiving end from determining that the transfer is actually a “dump” until it is too late to send the patient back
Medical records censor, Bigg-Chartman, excells at intercepting discharge and admission summaries. “She is medically knowledgeable, and she is the best at ferreting out those few specific lab tests that were essential for receiving hospitals to nail the diagnosis,” related Jimmy Blake. And the receiving academic hospitals almost never succeeded in sending a patient back —she had a 99.4% success rate. “They couldn’t figure out what was missing from the chart until it was too late,” said Flynn Barrows, Bigg-Chartman’s colleague in medical records. “I don’t know how we’d get patients transferred without her, she’s the best.”
Mai T. Casey, MD, Chief Medical Officer at Good Samaritan, provided her hospital’s view point. “Why should we do all of the hard work while the ivory tower folks get all the credit for saving the patient? Casey explained that the MRC makes the referring hospital look better. Casey added, “the only thing a discharge summary is going to show is that maybe one of our docs barked up the wrong tree, or in some cases ran a bunch of expensive tests but still came up empty-handed. The university docs should strike out a few times, also.”
