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Wiki opening chart before the patient arrives
- Thread starter oconnell
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danskangel313
True Blue
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This document is old, but see Section III, D.
http://policy.ucop.edu/doc/1100168/LegalMedicalRecord
"All Medical Record entries should be made as soon as possible after the care is provided, or an event or observation is made. An entry should never be made in the Medical Record in advance of the service provided to the patient. Pre-dating or backdating an entry is prohibited."
Personally, I'd consider the practice of accessing the record, creating the encounter, then auto-populating the data into the visit note as an "entry".
http://policy.ucop.edu/doc/1100168/LegalMedicalRecord
"All Medical Record entries should be made as soon as possible after the care is provided, or an event or observation is made. An entry should never be made in the Medical Record in advance of the service provided to the patient. Pre-dating or backdating an entry is prohibited."
Personally, I'd consider the practice of accessing the record, creating the encounter, then auto-populating the data into the visit note as an "entry".
Pam Warren
True Blue
Most electronic health records have a repository where test results are either interfaced or scanned in as part of the patient's medical record. To my knowledge, there is no issue with accessing the patient record in order to do that, and in most cases results must be signed off by the provider as to him/her having seen them. The patient does not have to be in the room, in the building or even in the state in order for the electronic chart to be maintained in that manner. Electronic health record software is different from product to product, but the concept is the same. The practice workflow determines when the patient 'encounter' is created for that day's visit. In our organization, the encounter is created upon check in and then the chart document is opened upon rooming by the medical assistant. The results are typically accessed by the medical assistant and can be viewed in a different tab. At that point, the physician would view any results that were stored in the chart, and wouldn't document any comments in today's note until he was with the patient, or afterwards. But having the results up and available in advance of the provider seeing the patient is simply good workflow, as long as the patient is ready to see the provider. Technology has changed the concept of the medical record, and we still have to maintain the integrity of the record, but we can certainly view electronic documents just as we'd view a paper document in advance of a patient's appointment if it prepares the provider in advance. We just wouldn't open an entry until the patient shows up.