Medical Writing and a Day with Infusion coding....

As usual... i switched off my alarm at 5:30 itself... but... woke up at 6:15.... God... I am going to miss office bus... its a wonder how i manage to get ready... but sharp 6:35, i found my self dressed up in a black t shirt and favourite blue jeans and pair of sneakers...

Wearing my access card, locking door, running down stairs, and dialing ma friend, to know bus position, happened in less than a min's time... "Dude where are u?..... still not ready??????????" My friend yelled in the phone.. But... God's Grace, moment i am out of the gate, i found my driver stopping bus for me. 

Once in the office as usual, after a coffee from cafe, i am in training room again...

Its new module from today... Infusions and injections.

Moment i opened the chart in ma system, i was getting crazy...

I was about to call my proctor thinking that IT people loaded some kindergarten child's scrapbook in the system instead of a medical record of some unknown patient, treated by some unknown physician, in an unknown hospital in USA. 

"Stopppp.... Think Again..... Have u seen this type of charts before????? "... my mind is calling me.... oh yes..... these are our "nurses notes"... it took me back to my college days again.... 

I was feeling like the same old day; first day in my clinics, when i blinked looking at the bundle of papers in a blue file, which is so called "case sheets" of unlucky fellows lying on the beds just a glass wall away, to find out vital sign's column, when the staff nurse asked me to record it...

"Why cant these people write it in good way...? this is hell... cant read out a single line from this..."

i heard my co- worker  losing his temper...

They are paramedics, most of them deals with lab only.... All of them can read one line in every  chart " blood samples and urine send for examination"

I peeped to see what my Dr Co-worker is doing...... I found him lost in those scribblings in the so called "case file" trying hard to find out that "o" like structure is "a"; if so why cant they put a tag over that?, or is that "u", then why cant they open up the top portion completely?, or is that "o " itself?, then why cant they close it properly so that it wont look like "u or a". I think being a homeopathic physician he never took a look into an allopathic nurse's report.

Doubt for my biotech friend was that "d/cd" is "disconnected" or "discontinued" or simply "discharged"..... Question pointed to me..... Gosh.... She is expecting me to answer..... "Infact..... " i cleared my throat thinking what to tell, " well... it could be anything of these... depending on scenarios".... cheers to my trainer... those were her golden words, which i borrowed to tackle that situation..

Our trainer is lucky enough..... she is not in the scene yet.... other wise she will be forced to run around in the training room to unlock mysteries of "o" and "u", "d/cd" and "POs", "IVP" and "IVPB"...

Those reports were in fact horrible..... Only two of our team had exposed to handwritten "case sheets" as we both were nurses. And we, as nurses are supposed to read it fast and act up on that in clinics... But... here, we are just coders... " we think like a coder, we act like a coder"... I can understand how stressed those nurses when they wrote those cases in between heavy schedules, as i was a nurse once. But still guys.... " Document it properly.... so that we can help u in reimbursement...

What ever work or care they provided to patient, i could see how they  are losing money, as documentation lacks sufficient data for code to be assigned.

More than 6 charts were lacking enough data and proved no codes could be assigned... How pitty...

With much struggle, when i clicked submit all... i was relaxed.. at least i finished it...

But i saw down and stressed faces all around and my nurse colleague running around trying to help them by reading those charts.

i saw my trainer supporting her head in her hand, seeing the scores...

All have just once comment...." Document not clear....!" But guys... we are in coding and we have to learn it.... any way... it was time to wind up show for the day.... Discussion is scheduled for next day...

Back in bus heading home.... i found one of my colleague on my right side sleeping and other one in left side with a stressed face... " Whats matter dear?..." i asked....

"If this is what we need to handle, then i don't think i can make it up....." she replied...

Oh come on.... we are now out of office... even out of Technopark campus.... Relax dear.. u r still with the codes.....?

what ever its is... where ever we go....

All we have to think is about codes...

All we talk are about codes...

All we have to do is just... Code... Code.... and Code...

God help Us....