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Record/chart keeping

  1. #1
    Default Record/chart keeping
    Medical Coding Books
    Just looking to see how everyone else does this. Do you guys keep 2 charts for each patient, one for the medical portion and one for the psychotherapy notes, or do you just keep one chart and abstract the therapy info from it before you send notes out to insurance or where ever?

  2. Default
    We used to keep 2 seperate charts, but now we have 1 combined electronic record. When we 1st went to the EMR the MH/SA service notes were behind a special firewall so that only those in that department had access to them. Now the firewall has come down and all clinical staff throughout the organization has access to this information...those w/o clinical need have to have a special override on their log-in in order to see it (billing/scheduling staff).

  3. #3
    That sounds about like what I have to do. I have special security, but the rest of the organization has a firewall and it is tracked and anyone without need to know will be in big trouble if they cross it.

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