Does anyone have a sample policy or process that speaks to unsolicited ER records for patients that have not been seen in years by our provider? Is there a best practice for whether to scan them into the record or send them back to provider?Our scenario is we have ER's sending records to us for patients that have not seen our physicians in three or more years. From a compliance standpoint, I am trying to figure out what to do with them.
------------------------------Sarah JacksonCompliance Manager------------------------------
HEALTH INFORMATION MANAGEMENT DEPARTMENT
Key Functional Area: Medical Record Operations
Original Effective Date: September 1, 2017
Effective Date of Current Revision: September 1, 2017 effective – January 1, 2014 ]
Review/Revision Date(s): May 17, 2018; November 4, 2020
Scope: All DCMC HIM Sites – Including Off-site Clinics
Policy Number: HIM-MR-3
Revision Number: Replaces Policy:
Defined terms are "Capitalized." Definitions are embedded in or included at the end of the Policy.
Purpose: To provide guidance on how to manage advance directive documents and/or other external patient health records received when there is no DCMC patient health record on file. Note: DCMC will not create a patient health record for the sole reason to store scanned or paper records from an external source.
Policy Procedure Statement/s:
Responsible Leader: Nancy Davis, Director of Compliance & Safety
Consulted With: Social Services and Spiritual Services Departments
Name/DOB/Address of Individual: __________________________________________________________________________
Dear Sir or Madam:
Door County Medical Center has received copies of the following healthcare records on you to be maintained in our files:
We strive to have a complete and accurate health record for every patient who receives services at Door County Memorial Hospital.
Unfortunately, we have no record of you ever being seen at Door County Medical Center. Without an available patient health record for you on file, we have nowhere to "attach" the records that were sent to us. We cannot create an account/patient health record without having services provided to you as a patient.
We will maintain the records we have received in our files for six months. If at the end of that period you have not received services/established a patient health record, we will destroy the documents in a confidential manner.
Health Information Management Department
Door County Medical Center
Copy: Attached Copy to Records and Hold Six Months