Health Information Technologies and Processes

Documentation of items in "paper chart"

  • 1.  Documentation of items in "paper chart"

    Posted 18 days ago
    Hello,

    I was wondering if anyone could help me here...currently in our office (private practice) we use an EHR. However, we still have a paper chart for loose documents that need to be scanned into the EHR for each patient. Here is an example:

    Patient is coming in to review MRI results. Under the HPI, the scribe indicates the reason for the visit and then documents: "MRI results in paper chart."

    There is nothing noted in the progress note about what the results were and the report is not scanned in for reference.  There may be a diagnosis that was determined by the results of the report documented in the progress note, but again, there isn't anything to reference to support the diagnosis in the EHR. If we were to be audited and an auditor came across this scenario, would we be out of compliance? Or could we provide the paper chart to the auditor for reference? Would that be sufficient? I know the rule is things need to be easily inferred - would this be easily inferred if the medical record is essentially in 2 different forms?

    Thank you to anyone who can provide any guidance!

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    Dana Collar, RHIT
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