Jenkins arrived in the operating room $($OR$)$ Suite at $8$:$45$ am to perform surgery on an elective surgery case for $9$:$15am.$ The OR supervisor requested to speak with the surgeon to explain that the case would have to cancel because of history and physical $($H&P$)$ report had not been completed for the patient's record.

Dr$.$ Jenkins because visibly upset and began making accusations, saying that he had dictated the H&P three days ago and that the HIM department was at fault. The OR supervisory was already aware that her secretary had phoned Mr$.$ Rheems, the Health Information Management $($HIM$)$ director, the day prior to inquire on the H&P report. The dictation system transcription report reflected that no dictation was available then. The OR supervisory informed Dr$.$ Jenkins that as of yesterday afternoon there was no dictation found in the system, but that she would inquire again with the HIM department.

The transcription supervisor searched the dictation system again immediately upon receiving the call and noted the H&P report had been dictated $45$ minutes earlier, at $8$:$15$ am$,$ by Dr$.$ Jenkins, and informed the HIM director that it would be typed as soon as possible and delivered to the OR$.$

The transcription supervisor informed Mr$.$ Rheems that Dr$.$ Jenkins had done this on two other occasions during the past few months. Mr$.$ Rheems knows the dictation system has tracking and audit capability for reports that reflect the date, time, and author of dictation, as well as identifying the date, time, and transcriber of each dictation.

In your final paper, discuss the following:

Research the use of a Health & Physical $($H&P$)$ report in Health Care.

Why is an H&P report important?

Which health care professional writes the H&P report?

How should Mr$.$ Rheems respond to the OR regarding Dr$.$ Jenkin's H&P report?

Should this individual incident be taken to administrative staff? If so$,$ to whom?