Health Information Technologies and Processes

Outside Records, Patient Drop-Offs Scanned into EHRs

  • 1.  Outside Records, Patient Drop-Offs Scanned into EHRs

    Posted 03-10-2020 11:28

    Hi Everyone,

    A. Patient drop-offs not ordered by our providers- Patients just want us to include them in their  records. My issues are:
    1. What if there are "clinically material" in those records but since the patient does not have a current medical concern, there's no reason to see our Providers so they just drop their records off.
    2. CEs always say they, not the patient, own the records. So are CEs not supposed to know what's inside of what they own and in turn be held liable if they missed something?

    3. What if down the road, there's a ligation that stems from a record/document that we provided in response to an ROI request. Will they hold the CE liable? And will that be tenable?

    Maybe tell patients to keep them for their PHRs?

    B. Records ordered by our Providers, we give them to our providers where they agree and notate: pls scan; so these we do scan. Can anyone share your process on this?

     Thank you all for your input.




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    Susan A. Oliver
    RHIA, CHPS, CPC
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  • 2.  RE: Outside Records, Patient Drop-Offs Scanned into EHRs

    Posted 03-11-2020 06:38
    I feel this all depends on the type of care you are providing. For instance,  I work at a behavioral health hospital. If i would have received them, I would recommend to the patient to keep them.
    If I work at physician office,  I would take it to my physician to review and go from there.

    Victoria Maans,  RHIT 





  • 3.  RE: Outside Records, Patient Drop-Offs Scanned into EHRs

    Posted 03-11-2020 12:23
    I appreciate your response, Victoria.

    Susan

    Sent from my iPad




  • 4.  RE: Outside Records, Patient Drop-Offs Scanned into EHRs

    Posted 03-12-2020 12:54
    Hello,
    There is an good practice brief from Ahima that you might want to check out.  Title is Managing Unsolicited Health Information in the Electroni Health Record (2016 Update).  I hope this is helpful.

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    Madeleine Sanders,
    Manager of Health Information Services
    Overlake Hospital Medical Center
    Bellevue, WA
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  • 5.  RE: Outside Records, Patient Drop-Offs Scanned into EHRs

    Posted 03-12-2020 19:12
    Hi Madeleine,

    I actually did because I need answers ASAP. Thank you though for researching with me.
    It actually addressed all my concerns that were shrugged off by my leadership who are not HIM SMEs so it is always nice to have HIM luminaries work as source document to prove our case. Now, they have a “problem” to deal with.

    Thank you, AHIMA!

    Sent from my iPhone