Q. In my family medicine practice, we’ve been using an electronic health record (EHR) for eight months. We picked a starting date and went 100-percent digital moving forward. We don’t scan old paper charts into the EHR unless they have necessary patient information (and of course we still keep all medical, billing, and payment records for the required amounts of time).
My question is: When we pull a paper chart to scan it, what information should we scan? Should we include letters from other physicians? Insurance information?
A. When practices scan information from a paper chart, typically these are the minimum items they include, according to TMA Practice Consulting experts:
- Problem list (chronic conditions, hospitalizations, procedure and surgery histories);
- Current medication list and allergies to medications;
- All immunization records (especially if not recorded through ImmTrac or other registries);
- Last progress note or up to two years of significant history (history and physical, review of systems);
- Last annual physical including patient-completed history form;
- Any significant procedure reports (e.g., significant imaging, colonoscopy, EKGs); and
- Significant or last lab reports (e.g., last chemistry profile, diabetes screening).
This is not an exhaustive list. Depending on the patient case or specialty, a physician may need to keep more information — for a patient who has had skin cancer removed, for example. New problem lists, medications, allergies, and immunization records should be entered as patients report for new appointments. To capture patient information in a retrievable format, data should be entered to be searchable and reportable for quality indicators and meaningful use. You should consider the realities of your practice, your style, the accessibility of old records, and how often you actually need old charts.
Because some judgment is involved, TMA Practice Consulting recommends you create a list of information you want scanned and have staff follow that guideline for every patient case. Or, some offices pull the paper chart for each new electronic visit, and the physician reviews it. He or she marks the pages of the record pertinent to the new visit. Afterward, a staff member scans what the physician referenced into the EHR, marks the front of the paper chart with an “X” and a destroy date, and sends it into archive or remote storage.
Published Aug. 26, 2011
TMA Practice E-Tips main page
Last Updated On
February 11, 2015
Originally Published On
August 26, 2011