Health Information Technologies and Processes

Diagnostic vs educational records

  • 1.  Diagnostic vs educational records

    Posted 23 days ago
    HI all,

    Hope you can assist or provide feedback.

    Images are captured using a device not interfacing with the EHR.  The device stores images in the cloud (it is vetted as secured).  The provider documents on the EHR.  Do images need to be viewable and accessible to other providers treating the patient?  Do they need to be filed within the EHR?

    Your input is valuable and greatly appreciated!

    Have a good day,
    Leah

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    Leah Beck, RHIA
    HIM Director, Interim
    Arrowhead Regional Medical Center
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  • 2.  RE: Diagnostic vs educational records

    Posted 23 days ago

    Hi,

     

    If images are taken for patient care and during patient care then yes, they belong in the EMR. We are looking for a solution on how to properly capture images during surgeries and get them into our EMR.

     

    Thanks,

    Karla

     






  • 3.  RE: Diagnostic vs educational records

    Posted 23 days ago
    Hi Leah,
    I think if you define this storage software as part of your legal health record, you may be okay. We have both a linked and non-linked systems at our organization.  We do have a link to our PACS system through our EHR. The image isn't stored in the EHR, but the link allows all providers to view the image. Contrary to that, we have an fetal monitor system that does not have a direct link from our EHR. Any documentation done on the fetal monitor strip does flow into the EHR, but the tracing itself has to be viewed from the fetal monitoring system. Not all providers have access to that system, only those who would care for an obstetric patient. However, we do have it defined in a policy that fetal monitor tracings are stored in Obix.
    Katie

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    Kathryn Wood, RHIA
    Assist Dir of Information Systems/Privacy Officer
    War Memorial Hospital
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