Confidentiality, Privacy & Security

External Documents

Judy J. Egan, RHIT,Lean Healthcare Black Belt Certification01-15-2014 11:11

  • 1.  External Documents

    Posted 01-02-2014 13:02
    Looking for some insight as to how others are managing external copies.  When your facility receives copies of medical records from outside facilties, are you making those part of your legal medical record?  We have varying practices happening within our organization and are looking to standardize the process.   It is the policy at the facility I came from that these were included in  the LHR.  Care decisions were (or could be) made based off information from those documents and therefore needed to be a part of the record.  I have other sites who scan the copies to the record but they aren't considered part of the LHR. Appreciate thoughts/comments anyone is willing to share.   

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    LeAnne Bouma
    Enterprise Director, Release of Information
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  • 2.  RE:External Documents

    Posted 01-03-2014 07:55
    Post HIPAA - if the information is used to make healthcare decisions about the patient, then it is part of the DSR/LHR.  If a provider feels it is necessary to retain the information in the patient's health record, than I cannot see how it would not be part of the DSR/LHR.  We try to have the provider make a decision about retention of external records - but not always successful.

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    Nancy Davis
    Director of Privacy/Security Officer
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  • 3.  RE:External Documents

    Posted 01-03-2014 09:32
    We include them as part of our LHR for the same reason you state: care decision may be made off of the information contained within them, thus, they should be part of our record.

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    Seth Katz
    Assistant Administrator, Information Management and Program Execution
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  • 4.  RE:External Documents

    Posted 01-15-2014 11:11

    Interesting discussion. If we receive the documents on paper, then they are scanned into our system and made a part of the record. What are you doing in the event the documents are received via CD such as radiology films/reports?
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    Judy Egan
    Director Health Information Services
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  • 5.  RE:External Documents

    Posted 01-16-2014 08:07
    Any radiology CD's that come to our dept. with a chart are forwarded to Radiology where they are loaded into the PAC's system.

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    Wendy Mangin
    Director Health Information Department
    Good Samaritan Hospital
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  • 6.  RE:External Documents

    Posted 01-17-2014 10:26
    I work in an outpatient setting and we route the external records to the clinician treating the patient for review.   They initial and date that they have reviewed them and then they are scanned into the LHR. 

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    Robin McKee
    Medical Records Supervisor
    Samartin Center/Gsh
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  • 7.  RE:External Documents

    Posted 01-20-2014 10:12
    External records are to be used as they were meant to be used.  Some physicians will bring their less than 30-day old office H&P, and now wants it used as the H&P for an inpatient encounter.  Other patient care records are sent, because the referring/primary care physician most likely want Hospitalist to review the patient's history.  This is mostly done when a referring/primary care physician does not trust the patient to provide the information that should be related to the caring physician. 

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    Ed Sanchez
    HIM Director/Privacy Officer
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  • 8.  RE:External Documents

    Posted 01-16-2014 10:27
    We also scan outside records into our LHR for the same reasons stated below.  As far as records received in electronic format (e.g. CD, DVD or USB drive) we import those into our LHR also; they are converted from a PDF into a TIF in the import process and they then function as if we had simply scanned them.  Radiology reports are scanned into our LHR.  For radiology films we rarely receive physical media any longer - for digital scans they are imported into our PACS.

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    Michelle Layton
    Director of Electronic Health Information
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  • 9.  RE:External Documents

    Posted 01-16-2014 10:51
    Same thing.  If it's documentation on a CD, we upload that to the EMR.  If it's radiology films, we upload that into our PACs system.

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    Seth Katz
    Assistant Administrator, Information Management and Program Execution
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  • 10.  RE:External Documents

    Posted 01-16-2014 11:48
    We scan paper records from outside facility and incorporate as part of our records.   Films and images from CDs are imported through a software and become part of the record as well.  

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    Leah Beck, RHIA
    Director, HIM
    Loma Linda University Health
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  • 11.  RE: External Documents

    Posted 07-11-2018 12:47
    We scan external records to the patients record when they come to HIM from the floors.  If we receive it in HIM, we assume that it could have possibly been used for medical decision making and to treat the patient.

    Can anyone point me to the specific regulation that states external records become part of the legal medical record?

    If external records are considered a part of your legal medical record, do you consider them a part of your designated record set?  When records are released do you release external records?

    Thank you for your guidance.


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    Ashley Friedrich
    HIM Director & Privacy Officer
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  • 12.  RE: External Documents

    Posted 07-12-2018 05:24
    Ashley,

    There is not state law about incorporating records into a 'Legal Health Record'. That is done via policy / procedure and yes they are definitely part of a DRS. if you bring any records into your record system they then become part of your record set(s).  Don't bring them in (scan, etc), return or destroy them (logging their destruction) if you don't want them in your record set. This is a very, very common practice. Once in the EHR or as images, it's hard to know if the clinicians used them for care, so they are assumed to be used for care. In court you could not attest to anything about their origination, but could attest to your care and maintenance of them once in your system. So Accuracy, Trustworthiness and Reliability that you could be asked to attest to change with these records as your site was not the original source creators, but did maintain them within your records. If you need more, just ask me directly.

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    Kelly McLendon, RHIA, CHPS
    Managing Director
    CompliancePro Solutions
    kmclendon@complianceprosolutions.com
    321-268-0320
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  • 13.  RE: External Documents

    Posted 07-12-2018 07:18

    Does anyone have a policy around outside records they would be willing to share?

     

    Debbie Parenti, RHIT
    Director
    Health Information Management (HIM)
    Mon Health Medical Center
    1200 J. D. Anderson Drive
    Morgantown , WV 26505
    304-598-1914 Phone
    304-598-1369 Fax

    Connect With Us: MonHealth.com | Facebook | Twitter

    https://mhsnet.monhealthsys.org/Uploads/Public/Images/Logos%20-%20Buttons/logo-signature%20new.jpg

     

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  • 14.  RE: External Documents

    Posted 10-04-2018 12:52
    ​We keep the records as part of the DRS.LHR, my question is do you break them out to each specific form type when scanning, scan in one big group, does anyone have a policy and procedure they are willing to share.

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    Kimberle Johnson
    [Director HIM/Privacy and Compliance Officer]
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  • 15.  RE: External Documents

    Posted 07-12-2018 09:54
    ​We do consider external records part of our designated record set.  We release these external records only when requested.

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    Kathryn Boyes
    Director, HIM
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  • 16.  RE: External Documents

    Posted 07-12-2018 13:07
    ​Hello
    External records are part of the Designated Record Set.  As such, if these records are requested you are obligated to release them.

    Thank you

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    Madeleine Sanders,
    Manager of Health Information Services
    Overlake Hospital Medical Center
    Bellevue, WA
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  • 17.  RE: External Documents

    Posted 07-12-2018 13:29
    Typically health care decisions are made from those records, which is why the providers need them in the first place. In the clinics I managed in the past, we always kept them as part of the legal health record.

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    Tresa Ryan, MBA/HCM, RHIT, CCS-P
    Director, Health Information Technology
    Missouri State University - West Plains
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  • 18.  RE: External Documents

    Posted 08-29-2018 11:02

    Agree with what others are stating, external records that are scanned or indexed into our EHR are included in our DRS. We only release external records when/if they are explicitly requested. The requests we receive are worded to make this clear- Records requested from: [FACILITY NAME], with additional field to add other entities.

    Follow up question for those who use Epic as their EHR: do you also treat records available via Care Everywhere the same as external records (i.e. if available for provider review, assume they are used for care decisions)? If so, are you also releasing these records...and if so how?

    Thank you



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    Vicki Dunn,RHIT,CHPS,CCS-P,MPA
    HIM Director
    Mary Greeley Medical Center
    dunn@mgmc.com
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  • 19.  RE: External Documents

    Posted 08-30-2018 08:52
    We do not release the records available via Care Everywhere.  These encounters are not selectable in our Releases workflow.

    We do scan external records to Epic; we use an encounter-level doctype "Outside Records".  If they were received as part of a specific encounter they are attached to that encounter.  If they are not specific to an encounter, we create a Scan Encounter and scan them to that Scan Encounter.  We can release the Scan Encounter through Releases, but we only select this encounter if it is in a date range of encounters requested.

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    Janet Baucom, RHIA, CCS
    Director HIM
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  • 20.  RE: External Documents

    Posted 08-31-2018 07:16
    Hello Vicki,

    Please note that some hospitals or facilities have a non disclosure clause. In other words records from those facilities must only be released after a patient has signed an authorization form compliant with the 42nd Code of Federal regulation on Substance Use Disorder. In my cases, I normally refer the patient to the facility that issued the documents requested. I am only responsible for what my facility physicians have documented.

    VICTOR N. MOTURI
    Health Information Consultancy