Confidentiality, Privacy and Security

Hello -

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.

Thank you

Sarah

------------------------------
Sarah Jackson
Compliance Manager
------------------------------

Hello -

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.

Thank you

Sarah

------------------------------
Sarah Jackson
Compliance Manager
------------------------------

Hello -

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.

Thank you

Sarah

------------------------------
Sarah Jackson
Compliance Manager
------------------------------

Hello -

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.

Thank you

Sarah

------------------------------
Sarah Jackson
Compliance Manager
------------------------------

HEALTH INFORMATION MANAGEMENT DEPARTMENT

TITLE:  RECEIPT OF ADVANCE DIRECTIVES/HEALTH RECORDS – NO PATIENT ON FILE

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: 

1. When external documents are received from individuals, healthcare providers or other sources and there is no record of the individual ever being a patient at DCMC, the documents will be managed as follows:

1. Stamp or write date of receipt on the front page of the documents.
2. If a legible name and address exists (or can be found) for the individual on the documents, complete attached notification letter and:
   1. Send original to patient; and
   2. Attach copy to documents.
3. Store documents for six months in a holding area in the HIM File Room in case individual is seen as a patient at DCMC.

1. After six months of holding, verify individual has not been seen at DCMC and dispose of in a confidential manner.

Responsible Leader:   Nancy Davis, Director of Compliance & Safety

Consulted With:   Social Services and Spiritual Services Departments

ATTACHMENTS:

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:

• Power of Attorney/Power of Attorney for Health Care
• Living Will
• Other Advance Directive-Type Document
• Copies of Health Records from Other Doctors/Hospitals/Healthcare Providers
• Insurance Correspondence
• Other: __________________________________________________________

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.

Sincerely,

Health Information Management Department

Door County Medical Center

Copy:   Attached Copy to Records and Hold Six Months

Hello -

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.

Thank you

Sarah

------------------------------
Sarah Jackson
Compliance Manager
------------------------------

HEALTH INFORMATION MANAGEMENT DEPARTMENT

TITLE:  RECEIPT OF ADVANCE DIRECTIVES/HEALTH RECORDS – NO PATIENT ON FILE

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: 

1. When external documents are received from individuals, healthcare providers or other sources and there is no record of the individual ever being a patient at DCMC, the documents will be managed as follows:

1. Stamp or write date of receipt on the front page of the documents.
2. If a legible name and address exists (or can be found) for the individual on the documents, complete attached notification letter and:
   1. Send original to patient; and
   2. Attach copy to documents.
3. Store documents for six months in a holding area in the HIM File Room in case individual is seen as a patient at DCMC.

1. After six months of holding, verify individual has not been seen at DCMC and dispose of in a confidential manner.

Responsible Leader:   Nancy Davis, Director of Compliance & Safety

Consulted With:   Social Services and Spiritual Services Departments

ATTACHMENTS:

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:

• Power of Attorney/Power of Attorney for Health Care
• Living Will
• Other Advance Directive-Type Document
• Copies of Health Records from Other Doctors/Hospitals/Healthcare Providers
• Insurance Correspondence
• Other: __________________________________________________________

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.

Sincerely,

Health Information Management Department

Door County Medical Center

Copy:   Attached Copy to Records and Hold Six Months

Hello -

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.

Thank you

Sarah

------------------------------
Sarah Jackson
Compliance Manager
------------------------------

HEALTH INFORMATION MANAGEMENT DEPARTMENT

TITLE:  RECEIPT OF ADVANCE DIRECTIVES/HEALTH RECORDS – NO PATIENT ON FILE

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: 

1. When external documents are received from individuals, healthcare providers or other sources and there is no record of the individual ever being a patient at DCMC, the documents will be managed as follows:

1. Stamp or write date of receipt on the front page of the documents.
2. If a legible name and address exists (or can be found) for the individual on the documents, complete attached notification letter and:
   1. Send original to patient; and
   2. Attach copy to documents.
3. Store documents for six months in a holding area in the HIM File Room in case individual is seen as a patient at DCMC.

1. After six months of holding, verify individual has not been seen at DCMC and dispose of in a confidential manner.

Responsible Leader:   Nancy Davis, Director of Compliance & Safety

Consulted With:   Social Services and Spiritual Services Departments

ATTACHMENTS:

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:

• Power of Attorney/Power of Attorney for Health Care
• Living Will
• Other Advance Directive-Type Document
• Copies of Health Records from Other Doctors/Hospitals/Healthcare Providers
• Insurance Correspondence
• Other: __________________________________________________________

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.

Sincerely,

Health Information Management Department

Door County Medical Center

Copy:   Attached Copy to Records and Hold Six Months

Hello -

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.

Thank you

Sarah

------------------------------
Sarah Jackson
Compliance Manager
------------------------------