Becky speaks of having forms in her office that aren't part of the medical
chart.  We did this for some time until someone discovered it and was all up
in arms saying that it constituted "shadow charts" since if it was important
enough to write down it needed to be in the official record.  Otherwise,
there could be legal ramifications.  In fact, we were told the hospital
could be fined several thousand dollars for EACH such form if JCAHO became
aware of them!  Not sure if this is a universal interpretation or if the
person we dealt with was overly paranoid.  


We did have a log for all calls.  There were about 6 spaces on each sheet.
We would record the date, name and brief description of the call.  Since
most calls came in to our answering machine, this was critical.  The person
taking the message might not be the one to reach the mom to answer it.  We
could then indicate when the call was returned, by whom and a brief note
about what was said.  If is was a simple informational call such as asking
when our classes were or the like, that was all that was needed.  In some
other cases, we could document in the space provided.  An example might be a
question about how long to store breastmilk.  We would note something like
"guidelines read" which meant we read the guidelines that were currently
being used by the hospital.  Since these were not individual forms, I guess
the "shadow chart" label didn't apply.

 

We were using TLC at the time, and each mom that had delivered at the
hospital was already in the system.  Otherwise, we started a file on her if
it was more of a counseling call.  We then printed up a summary which went
to Medical Records.

 

Since I retired, they have gone to a much more inclusive computer system and
I don't think TLC is part of it, so I'm not sure how the phone calls are
being handled under it.

 

Winnie

 

 


             ***********************************************

To temporarily stop your subscription: set lactnet nomail
To start it again: set lactnet mail (or digest)
To unsubscribe: unsubscribe lactnet
All commands go to [log in to unmask]

The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(R)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html