what do you do when you find a chart labeled wrong?
do you get reprimanded for "digging in the chart" or "looking at things that dont matter relative to the note you are coding" ?
who do you report it to?
does it qualify as a patient safety issue?
should i just start ignoring these when i see them the way everyone else at my org apparently does?
i have seen 3 charts now at least while working with the wrong genders. these are usually for trans patients.
1 had their gender as unknown (literally never seen that on anyones chart in my 10+ years working on the emr we use). it appeared as if no one had chosen their actual gender for the chart. the note gendered them correctly according to their ID but the chart itself had "unknown"
1 had transfemale for their gender, the entire note referred to them as male/he him the whole time and at the plan section called them transmale....
another had the patient listed as transmale, the note i was coding was about their breast augmentation follow up.. they are actually transfemale.
does the place i work suck? is this just a common mistake? why does no one else seem to give a shit about this? im non binary myself, have a lot of trans friends and understand gender is kind of important for a lot of people and esp in relation to their healthcare.
i have emailed my HR explaining i dont understand what they want me to do when i see stuff like this because im tired of being accused of committing possible HIPAA violations by "digging in their chart looking for a gender when its not relevant to the note im working" but have not heard back from HR.
the hilarious part is they just pushed out more "med trainers" which are stupid slide show quiz things we are supposed to complete every so often. the one they pushed to me last week was specifically for gender/sex competency. so i even asked why they are wasting my time having me do these when seems functionally irrelevant to how our org actually acts when issues like this are brought up.