Wiki Medical Record Rentention-Encounters/EHR

[JessBojan]

Hello, I work for a reproductive medicine/infertility clinic, my office is currently filled with boxes of our 'encounter sheets'. I am trying to figure out if these all need to be scanned into our server before shredding or if they are even needed for the medical record. When patients come in, the nurses/doctors use an encounter sheet to mark off what labs/ultrasounds/etc. were performed, I then use these to verify services based on what's documented in our EHR (lab results, ultrasound images/notes, office visit notes, etc.) and then enter the appropriate charges into our billing software. If all of the labs and services are already in the patient's chart in our EHR, is it even necessary to keep these paper sheets? I've started the process of scanning them all into our shared drive, but since the encounters aren't always completely accurate and all of the information is documented in the patient's chart already I feel like these shouldn't need to be retained as well for 7 years? I can't find anything that addresses keeping paper forms along with EHR records and am hoping to save myself the daunting task of scanning in years worth of encounters. Thank you in advance for any advice/guidance/help! I appreciate it!
Jessica

 

[csperoni]

Billing sheets typically do not (and in my opinion should not) contain medical record information. It sounds like documentation is all done in your EHR (orders, findings, exam, treatment plan) and the clinician circles some numbers on a separate piece of paper for data entry. As long as all the numbers circled/entered are supported by the EHR documentation by words, I see no reason why those billing sheets are necessary to be retained. Billing sheets are also not signed by the provider.
In fact, I have seen many practices (if billing sheets are even still in use) to have them laminated & the circles are done with dry erase marker so the same papers are used hundreds of times and never saved.
If you have a compliance department or officer, you should definitely run this past them.

 

[thomas7331]

I agree, these things are a tool for communication within an office and aren't part of the medical record. There's usually no reason to keep (and no reason they would need to be scanned). No auditor is going to accept these as documentation to support any claims that have been billed, so even if you kept them, they likely would never serve any real purpose. But I also agree that someone should review these before discarding just to validate that there isn't any information written on them that might need to be kept as part of the patients' medical records.