I worked in Med Recs for 13 years....not only are there transcribers, clerks, coders and assemblers that have access to paper records. You have nurses, lab techs, EKG, X-ray and doctors that can look into your files.

Transciptions are usually History and Physicals, a note about why you are there seeking treatment, Operating Room reports, Discharge notes and Xray/CAT scan results.

The Doctor's notes and Nurses notes are also in these files-those are the daily observations of the people caring for patients-those notations that are sometimes more telling that a typed page taken off a tape.

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STE,

The problem is not hacking into a system! It's the effing lazy arsed docs who have to "sign" off on their notes.

It's required that a Doc's Order (on paper) has to be signed by a physician, A telephone order, taken by a nurse had to be countersigned by the doc.

I know of nurses who would "sign" for a doctor-The hospital nurses would write the order and when that chart went to the clinic, the clinic nurses would help the doc out.

So you can imagine the password swapping that will go on once an electric record goes on line!