The combination of paper, EHR, and document imaging (scanning) is causing challenges for Health Information Managers (HIM).
Paper forms are still utilized by some Healthcare Providers due to necessity or due to limitations of the EHR. Practitioners must be able to access and input information into an EHR or onto a form that will be later scanned into the EHR, and that information must meet legal requirements. There are many strengths noted in utilizing a Hybrid EHR. Hybrid records allow for paper and electronic records to be accessed by multiple practitioners at the same time.
These also allow for the Health Records Technician to ensure that the legal requirements of the EHR are met. Ensuring that practitioners can access lab results, radiology reports, previous notes from other visits, sending and receiving notes from outside referrals and other functions make Hybrid records valuable to the Health Providers. Some of the weaknesses of the Hybrid EHR become apparent only when actually implementing the process. When a document is scanned into the record, the HIM staff must ensure a crosswalk is created.
Crosswalks are structures within the EHR that include headings, such as “Discharge Documents”, and subheadings that are useful such as “Discharge Instructions”, “Discharge Summaries” or “Admission Information”. These crosswalks allow for a practitioner to access information electronically, and should be aligned with how the paper chart is accessed prior to the implementation of an EHR. Ancillary reports follow below subheadings. Physicians and nurses create paper charts, and that chart, when patient is discharged, is scanned into the EHR by an HIM.
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That data then becomes part of the legal document. A legal medical record is described as residing wherever the document is born. When information is created in the form of an electronic database, which is the legal record. The EHR must be considered a document that can be subpoenaed for legal proceedings. Signatures, whether electronic or paper, must be documented in a master list that follows the chart at all times. The master signature list ensures that anyone that accessed the record, added or deleted information, and had direct care for the patient is appropriately documented.
When a Request for Information (ROI) is generated, a hybrid EHR becomes a good choice. The hybrid record, when imaging is used, allows for complete releases by the HIM without having to data mine the paper records. This increases productivity in the HIM by decreasing the time to find and copy data, and decreased the amount of paper required when the ROI can be fulfilled with electronic data transfer instead of paper being sent. The “Willow Bend Record Policy” was established to establish guidelines for retention, storage, and destruction of health information.