Is it considered falsifying a medical record to write about a director's visit when the director hasn't been there? This question is just too interesting to resist answering.

Existing cases require a three-level check-in, which is a relatively short period of time after admission to complete the three-level check-in of the resident, the attending physician and the chief physician. General is required within a week, but in some cases is required within 5 days to complete the three-level check-up, how to say it, in the grass-roots hospitals are good to realize some of the general work of the chief physician is relatively fixed, in addition to the occasional academic conferences and so on, are in the hospital, most of the time within a week can be completed within the three-level check-up, but if it is in the provincial hospitals or regional hospitals, compared to Beijing and Shanghai, some of the large tertiary care hospitals However, in provincial hospitals or regional hospitals, such as some large tertiary hospitals in Beijing and Shanghai, the chief of the department is often also responsible for some other tasks, such as going out to give lectures, frequent recollections in the field, the government's work tasks, or even some surgeries and other urgent work. In such cases, the time set aside each day is actually very short, and sometimes there is really no way to lead the departmental doctors to check the room.

In addition, some department chairs also serve as vice presidents, department chairs, chief medical officers, etc., and have a lot of work to do, so there is no guarantee that they will be in the department for any length of time. So sometimes there is no guarantee of time to check the room, but usually the resident will also ask the superior physician, if the diagnosis of disagreement with the director of the department will also take the time to look at it.

In fact, such a requirement is also meant for the purpose of experienced senior doctors participating in the diagnostic process and acting as a gatekeeper for young doctors who lack experience. But in fact there are times when the title does not represent the ability. For example, my classmate assumes the position of chief surgeon in most of the surgeries in the department, and there are even some surgeries that only he can do in their department, but he is only the attending physician. So don't underestimate your attending physician, maybe he is the future big specialist?

The three-tiered system of checking rooms is not reasonable in the first place. There is a sequence of hearing, there are specialties, and the superior physician does not necessarily know more than you do!

That's an interesting question! Let me say a few words.

Just because you haven't seen the director visit you on the ward doesn't mean he doesn't have anything to say about your condition, or that the room visits we record are all made up!

We have a morning shift every day, which is to review yesterday's new patients and difficult and critical patients! After the morning shift, there will be a reading meeting, which is to analyze the patients in the hospital and arrange the next treatment plan! The following doctors will report the medical history, we will discuss it, and the director will make comments (this is what the director's check-in record is about)!

The director will personally come to the bedside to take a history and check on any patient that he is unsure about or that he is going to be the lead surgeon on!

No director has the time to follow a resident around every day to check in, and there's no need to! The director needs to go over it, and the following doctors will take the initiative to report it!

Also, what counts as falsifying medical records?

Alteration! As long as there are traces of alteration, Sensei is considered a forgery regardless of authenticity!

Records created out of thin air, for example, where it is clear that a certain test has not been done, a test is missing from the record, and then a certain disease is added, which is surely a forgery!

Improvement of the doctor-patient relationship has a long way to go! It requires the joint efforts of both doctors and patients! As the saying goes, there are always rat droppings in any profession! Please believe that most healthcare professionals are good people! We must also believe that there are many good people in the world!

Never checking the room is impossible.

The director usually only once a week to check the room, will not be every patient seriously look, just roughly over once, only difficult cases to analyze.

The managing physician is in charge of the specific patient, the director just guides it.

Minor illnesses are usually passed in one sentence.

The patient thought never checked in probably because it was a mild condition and the director just didn't look at it, a sentence went by and the patient didn't pay attention.

It's not falsifying medical records. Just because the director doesn't go to the room, doesn't mean he doesn't know the condition. There is a morning shift every day, and the conditions of some key patients will be brought up for discussion. Also, now the doctor's orders medical record system are electronic, in front of the computer can see the patient's diagnosis and treatment. Room visits should not be confined to the form, room visits are not necessarily to the bedside, to understand the condition, to guide the day's treatment program is also a kind of room visit.

The key is the relevant provisions that are not based on reality and do not start from a realistic perspective

First of all, you have to distinguish between the director of the hospital, the chief physician, and the bedside doctor. These three are not the same.

General cases are filled in by the doctor in charge of the bed, which is the practice of the hospital, the chief physician is mainly responsible for the patient's diagnosis and treatment, including room visits, which is also in accordance with the requirements of the director to do. Each patient's case has a departmental consultation after the specific allocation to which doctor is responsible for, which is a specific arrangement, not random selection.

The director is usually the administrative director, is not responsible for patient check-in, he is to arrange the whole department tasks, including the content of the meeting of the upper and lower levels, the spirit of communication.

The director's signature is required on each patient case. The chief physician will report the diagnosis to the administrative director, who will decide whether the patient can be admitted or discharged, or discuss treatment options.

As a patient, we have to listen to the doctor's arrangements, they are good, no one has a problem with who. Last year, I was hospitalized in Beijing Aviation Hospital, the administrative director has not seen, are the chief physician checkups, in the outpatient clinic to see the director, to be discharged from the hospital has not seen, the disease is good on the line, these are irrelevant.

Trust the doctor's medical ethics.

Thanks for the invite.

The title hospital director should be the deputy director or chief physician, otherwise it can be easily confused with the administrative director

Never checking in is definitely not a thing, it didn't exist in the hospitals I've been through before

The content of the medical record is not entirely the checkup of the superior physician instructions, which is the objective diagnosis and treatment system limitations, there is no specific department, disease, the severity of the division of the disease, for some of the routine less serious diseases is every physician should be able to deal with, otherwise all the disease need to director of the eye, have to die of exhaustion! But the course of the disease and the need for three-level checkups, can only be physicians based on the patient's daily record, which is two concepts with the forgery!

Even if there is a clinical situation of not checking in on time, the medical record needs the signature of the chief physician, and the signature is also a default and check, which means that it is responsible for it, and it is not a fabrication of false information, which is modified if it does not match the patient's situation.

Thanks again for the invite and I hope you'll follow me around!

The current three-tier system of hospital room inspections needs to be improved. This phenomenon is in the minority. It is also one of the inevitable results of emphasizing research over clinics.

There are two kinds of room check, one is bedside room check and one is non-bedside room check. A second level of physicians generally have bedside checkups, most of the third level of physicians will check the room once a week, which is the third level of physician checkup system requirements, but not not necessarily bedside checkups are not necessarily, you can bedside checkups, so that the patient can see the director of the face, but also may be the office checkups, analysis of the condition of the development of a treatment plan by the next level of physicians bedside checkups. If you are sure that the director has neither bedside checkups nor office and other types of non-bedside checkups, but the medical record written by the director of the checkups, according to the third level of physician checkups in violation of the system.