CONTACTS
SUBJECTS
VA EGD Procedure on 141107 Stricture Lower Esophageal Sphincter Valv
1503 -
1503 - ..
1504 - Summary/Objective
1505 -
150501 - Follow up ref SDS 2 0000.
150502 -
150503 -
150504 -
150505 -
150507 - ..
1506 -
1507 -
1508 - Progress
1509 -
150901 - Progress Notes have been missing longer than 2 months, from the VA
150902 - computer that stores patient medical records, for the EGD procedure on
150903 - 141107 0800. ref SDS 2 SY6M This morning checked again and found they
150904 - are still missing, despite notice to the doctor on 141125 0942.
150905 - ref SDS 3 OL6F
150907 - ..
150908 - Today, drove to Sacramento and stopped at the VA Medical Center in
150909 - Sacramento at Mather AFB.
150910 -
150912 - ..
1510 -
1511 -
1512 - 1307
1513 -
151301 - The attendant at the receptionist counter said that Doctor Lee has
151302 - already left for the day. He is scheduled to be onsite all day
151303 - tomorrow.
151305 - ..
151306 - Met with Jessica in the Gastrointestinal (GI) Clinic, and requested
151307 - again Progress Notes for the esophagogastroduodenoscopy (EGD)
151308 - procedure on 141107, and including photographs showing findings during
151309 - the procedure. ref SDS 2 RG9K
151311 - ..
151312 - Jessica seems to be an administrative assistant in the GI Clinic.
151314 - ..
151315 - Explained the doctor's Progress Notes are missing from VA medical
151316 - records for EGD dilation procedure on 141107 2000. ref SDS 2 SY6M
151318 - ..
151319 - Jessica checked the VA computer on her desk. She confirmed that the
151320 - Progress Notes are missing from VA medical records - she could not
151321 - find either Progress Notes, the doctor's letter to the patient, nor
151322 - photographs. She may have found the biopsy results. Jessica said
151323 - that keeping medical records posted is a hard job, because doctors and
151324 - the entire staff have a hectic schedule providing care and maintaining
151325 - an expanding list of administrative protocols.
151326 -
151327 - [On 150116 0813 met with Jessica at GI Clinic VA Medical
151328 - Center in Sacramento, she has notified Doctor Lee that
151329 - Progress Notes are missing for EGD Dilation on 141107,
151330 - ref SDS 5 MX5I; later that day at 0922 Doctor Lee called
151331 - and left voicemail message that his Progress Notes for the
151332 - EGD Dilation procedure on 141107, are missing from VA
151333 - medical records computer system; he further said the
151334 - missing Progresss Notes can be restored by scanning another
151335 - source; he will have the records restored and submit notice
151336 - to the patient when his Progress Notes can be downloaded
151337 - using the Internet to access the VA computer system.
151338 - ref SDS 4 ZX6I
151340 - ..
151341 - Jessica said to wait a few minutes while she discusses the missing
151342 - records matter with the supervising nurse.
151344 - ..
151345 - She returned about five minutes later.
151347 - ..
151348 - Jessica said the supervising nurse is not available. She will contact
151349 - both the supervising nurse later today, and ask Doctor Lee about the
151350 - missing records, when he comes in the office tomorrow morning, since
151351 - he has procedures all day.
151353 - ..
151354 - There is a general understanding that the doctor dictates Progress
151355 - Notes, and then they are transcribed by a typist. Something may have
151356 - happened to the dictation that has delayed transcribing, or perhaps
151357 - the notes were transcribed, and then not provided to the doctor for
151358 - signature. In both cases, the file will not be visible in patient
151359 - medical records on the VA computer system.
151360 -
151361 - [On 150116 0813 at 0922 Doctor Lee called and left
151362 - voicemail message that his Progress Notes for the EGD
151363 - Dilation procedure on 141107, are missing from VA medical
151364 - records computer system; he further said the missing
151365 - Progresss Notes can be restored from scanning another
151366 - source; he will have the records restored and submit notice
151367 - to the patient when his Progress Notes can be downloaded
151368 - using the Internet to access the VA computer system.
151369 - ref SDS 4 ZX6I
151371 - ..
151372 - Thanked Jessica.
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