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Medical records at UCI

October 02, 2008

Re "UCI hospital put under state supervision," Sept. 26

The Times reports that federal inspectors cited UCI anesthesiologists for a "practice of filling out medical records in advance, suggesting specific outcomes before procedures were done."

This is misleading. In all cases, UCI residents or nurse anesthetists correctly recorded vital signs, drugs and procedures at the time of treatment. The supervising anesthesiologist's notes, which made up just a small part of the record, were intended to confirm involvement in the patient's care.

For years, the department was underfunded and in deficit, which resulted in significant pressures from billing and compliance. These system issues resulted in cases in which anesthesiologists pre-documented their section of the chart to maintain case flow in the operating rooms.

With rare exceptions, the anesthetic record was accurate. Anesthesiologists supervised the anesthetics. There was no patient injury, no compromise of care, no fraud, no malice and no monetary gain associated with pre-documentation.

Nevertheless, pre-documentation did not meet UCI medical staff guidelines. In the last year of my term as chairman, I directed that pre-documentation stop, over a year before receipt of the recent Medicare report.

I am proud of our high standard of patient care and safety, which has been corroborated by numerous safety reviews.

It is a tribute to the training, skill and experience of our dedicated clinical faculty, most of whom still practice at UCI today.

Peter H. Breen, MD

Irvine

The writer is the former chairman of the department of anesthesiology at UCI Medical Center.

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