Question Medical Records Question

drashby

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Virginia Beach, VA
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We all are very familiar with ROI and the many HIPAA rules. How about rules surrounding receipt of records. I "grew up" in hospital systems running physician practices. Every system I worked in required review and signature by the provider; either electronically or wet. Some before scanning into the chart some after. I have now moved into private practice and started creating policies and procedures surrounding medical records. Based on my history in corporate environments, I just naturally (tried) to implement the same. Holy cow! It is like an act of congress to request an acknowledgment/review of records received. So then I started thinking, maybe its not required? What about unsolicited records? It is the physicians responsibility to review the chart, right? So if it is scanned in does he really need to sign off too? Am I asking too much? In my internet searches, I'm not finding anything about receiving the records. What info or guidance does anyone have? Very interested in your responses.
 

OpenClaims

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Miami, FL
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What exactly are you wanting the provider to sign off on? If was a Medical Records Analyst prior to my coding career. Every week we reviewed Pre, Intra, and Post-Op notes to make sure they were signed in the allowed timed. Office notes and any orders need to be signed, which I am certain you know based off of what you've said. What EMR system are you using? Is there an infrastructure in your software to send messages/reminders to your providers in-basket to sign off on things?

I know it's an in-basket with EPIC, Cerner has discerns.
 

amyjph

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Munising, MI
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Interesting question. I am not aware of any requirement for inbound records whether solicited or not. A physician should not be required to sign off on another provider's incoming records that I know of. It's not their documentation to sign off on. Some practices or hospital systems may have internal compliance or other policies which require it. If it's an external record and required for patient care and planning, the physician should acknowledge it, kind of like the in basket mentioned above. Some consulting providers I have worked with won't see the patient without the referring providers documentation which makes 100% sense, but they don't necessarily have to "sign it", they do acknowlege it and comment on it in their own records (usually). I think this would be a question for your internal compliance department. Have you checked the Conditions of Participation (CoPs)?
In large health systems on Epic for example, if all the records are in a shared system, I don't think it would be needed. In a small private practice, this may be different.
In my experience, it's difficult enough to get some providers to sign their own medical records in a timely manner.
 

OpenClaims

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I agree. If you're receiving records, I don't see why the provider would need to sign off on this. I personally have never seen this other than when a provider requests external records for some sort of surgical clearance.
Interesting question. I am not aware of any requirement for inbound records whether solicited or not. A physician should not be required to sign off on another provider's incoming records that I know of. It's not their documentation to sign off on. Some practices or hospital systems may have internal compliance or other policies which require it. If it's an external record and required for patient care and planning, the physician should acknowledge it, kind of like the in basket mentioned above. Some consulting providers I have worked with won't see the patient without the referring providers documentation which makes 100% sense, but they don't necessarily have to "sign it", they do acknowlege it and comment on it in their own records (usually). I think this would be a question for your internal compliance department. Have you checked the Conditions of Participation (CoPs)?
In large health systems on Epic for example, if all the records are in a shared system, I don't think it would be needed. In a small private practice, this may be different.
In my experience, it's difficult enough to get some providers to sign their own medical records in a timely manner.
 
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