Opinion ID: 511657
Heading Depth: 2
Heading Rank: 1

Heading: Operation of the Medical Records Unit

Text: 3 Shortly after she was hired, Phares was assigned the duty of setting up a medical records program at the Small Animal Clinic. After receiving training at Michigan State University, Phares designed case summary forms, as well as other forms, and established a filing and indexing system. 4 Clinicians used the case summary forms developed by Phares. Clinicians would complete a case summary form for each patient, indicating the diagnosis, prognosis, operation, and vaccination. The clinicians would then sign the form and submit it to Phares for abstracting. 5 Phares' duties basically entailed abstracting the information provided to her by the clinicians. 1 Phares reviewed the forms for accuracy and completion, ensuring that all of the laboratory reports and other materials were included in the medical record. Phares then abstracted the information from the case summary forms. This involved assigning code numbers to the diagnoses, prognoses, vaccinations, operations, and other pertinent information. Phares used standard reference texts and other coding lists to determine the proper code number to be assigned to each item. For each medical record, Phares entered the appropriate code numbers onto an abstract form. Phares then submitted the abstract form for entry into a computerized data retrieval system. Ultimately, the recorded data was sent to the Veterinary Medical Data Program at Cornell University, which gathers medical data from various institutions of veterinary medicine. 6 During the 1970's, an ongoing dispute developed between the veterinary clinicians and Phares concerning what information was required on the medical record to make it complete. Phares testified at trial that at times the diagnosis listed on a case summary form would appear to her to be incomplete. For example, lab reports might be added to the medical record after the clinician had completed the case summary form. If Phares believed that the lab report might change the diagnosis, she would send the medical record back to the clinician for review. Likewise, a clinician might list a diagnosis generally rather than specifically; for example, the diagnosis might be listed as cystitis as opposed to cystitis due to staphylococcus aureus. Rather than listing the code number for the general diagnosis on the abstract form, Phares sometimes returned the medical record to the clinician to determine whether a more specific diagnosis was appropriate. Many clinicians were unhappy with Phares' practice of returning the medical records to them for review. Because the records were sent to clinicians for review and were not promptly returned, a serious backlog was created in the medical records unit. In addition, difficulties arose in locating specific medical records because they were not in the appropriate files.