The Medical Record

The medical record is a legal document that has primary and secondary purposes. Primary purpose for the record is to document the patient’s health history. While secondary uses include research, billing and reimbursement. The patient has the right to view the contents within the medical record and may request to view his or her record at any time. This week, you are asked to respond to a scenario you may encounter.

Scenario:

You are a medical office specialist and have been asked to process medical record release requests for the week. As you were making copies of the medical records, you notice abbreviations written in the chart by a physician and RN that you have never seen or learned in school. You becoming increasing baffled as you continue to see these types of abbreviations. You finally ask the RN what does the abbreviations mean that were written by her and the physician? The RN explains that OULK means “one ugly looking kid;” CUEF means “clearly uneducated female” and “FAU” meant “fat and ugly.” The RN goes on to say, “no will ever know” and walks away laughing.

How would you respond to this discovery? How would you respond to the RN’s laughter? How could the R (Respect) in the "PRICE of Success" be used in this situation?

The OULK was from an actually chart that was written by a pediatrician who had to explain what this meant during a lawsuit on the stand in front of the child’s parents.