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医学文章阅读——Medical Records

发布时间: 2025-06-04 09:58:07   作者:etogether.net   来源: 网络   浏览次数:
摘要: Discharge charts had been stacked awaiting physician sign-off before they could be returned to Medical Records for sto...


An electrical fire in the physicians' dictation room left a charred mass of burned and water-damaged medical records. Discharge charts had been stacked awaiting physician sign-off before they could be returned to Medical Records for storage. Several medical transcriptionists spent 3 days sorting through the remains to reassemble the charts, all of which were from the patients of the large otorhinolaryngology practice. In addition to patient identification information, the transcriptionists matched word cues to create piles of similar documents. 


Middle ear and inner ear patients were identified with words such as stapedectomy, tympanoplasty, myringotomy, cochlear, cholesteatoma, otosclerosis, labyrinth, otitis media, and acoustic neuroma. External ear patients were grouped using terms such as otoplasty, pinna, postauricular, and otitis externa. Mastoid, laryngeal, and nasal surgery patients were grouped separately. Restoring the charts was an impossible task, and the records were determined to be either incomplete or a total loss. The only document to survive the fire was an audiology report.


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