Health Information Technologies and Processes

Protocols in chart

  • 1.  Protocols in chart

    Posted 12-23-2019 18:17
    Hi all,

    HIM is tasked to ensure protocols are on file for specific orders such as vancomycin intermittent pharmacy dosing, Zosyn extended infusion, Oxygen Therapy, Volumetric Diffusive Respirator, etc.  These need to be filed per order per patient.  So if there are several orders on same item whether cancelled or duplicated, they still need to be filed.  HIM would not be able to validate if so, anyway.  We electronically import the documents as copies of the orders are received and printed in HIM.  However, as mentioned, they get cancelled or were ordered a few more times by another provider if not caught.

    Have you heard of protocols being on file in the chart?  How are you handing it?  This is the first I've heard of it so I'm reaching out.  It is part of corrective action plan for accreditation.

    Any feedback is greatly appreciated.  Thank you and happy holidays!

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    Leah Beck, RHIA
    HIM Assistant Director
    Arrowhead Regional Medical Center
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  • 2.  RE: Protocols in chart

    Posted 12-24-2019 08:49
    Hi Leah, We do not keep protocols in the medical record. Copies of protocols are only released upon request. Following are a few scenarios when protocol copies have been requested: CMS record request, accreditation survey, records involved in litigation


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    Natalie Novak, MHSA, MBA, RHIA
    Executive Director Corporate HIM Division
    Franciscan Alliance
    Natalie.novak@franciscanalliance.org
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  • 3.  RE: Protocols in chart

    Posted 01-09-2020 10:25
    I agree with the respondent in addition we do need to ensure that all protocol orders are authenticated and each individual medical.

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    Lori Richter
    Ehr Compliance, System Director
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