Integrating Outside Records into the Active Patient Chart

It is not uncommon for the HUC to receive documentation from outside the hospital that must be added to the patient care record. This documentation may present through various methods:

• Patient-supplied records, including:
  • advanced directives,
  • medication lists, and
  • test results or copies of consults.
• Requests for records from health care providers through formal Release of Information requests, including:
  • copies of tests from outside diagnostic providers such as sleep study results or ECHO results, or
  • copies of prior surgical or consult records from previous admissions to other hospitals.
• OR Booking forms originating from specialist offices for inpatient and outpatient procedures.
• Requisitions for outpatient diagnostic procedures, such as MRIs, ultrasounds, or nuclear medicine tests.

Hybrid Patient Records

Adding outside records to the p-Chart is a simple process. If it is original documentation from the patient (such as a power of attorney or advance directive), the HUC will make a copy of the original for the chart and return the original to the patient. The copy is filed in the p-Chart under the most appropriate chart section, or in the miscellaneous section. If the documentation is already a paper copy, for example, received in a release of information request from another facility, the HUC would add it to the p-Chart under the appropriate section, history, or miscellaneous section.

If the record is received in digital form, for example, through email or a portal, the HUC may print the copy and file on p-Chart or upload it to the e-Chart, as per hospital policy.

e-Charts

With e-Charts, any outside documentation must be added to the chart electronically, as there is no p-Chart. Depending upon how it is received (e.g., electronic fax, portal, or a physical record), there may be different methods to do this, including:

• downloading the document, printing it, scanning it into the patient record
• dragging and dropping the document into the patient record, or
• downloading the document and uploading to the patient record (S. Bellefeuille, personal communication, February 21, 2024).

Best Practices When Scanning Documents to e-Chart

Each organization will have their own system for adding documents to the e-Chart; however, all processes should include:

• following correct naming conventions: barcoding, MRN#, or ANSI Standards Z1.4 (First Name, Last Name, DOB, HC #)
• confirming the correct electronic record
• confirming document quality and cross-referencing with original document(s) to confirm that
  • image quality is acceptable
  • all pages were scanned successfully
  • the images are in the correct order and rotation
• confirming document security, including saving documents as read-only and policies for the retention and destruction of the original physical or electronic record (Goodrum et al., 2020).

Adding Document to Correct e-Chart Section

Ideally, scanned documents are sorted into appropriate e-Chart categories; for example, a result for a scanned ECG is in the same folder as structured ECG tests. This allows for easier access to clinically relevant documents. However, some e-Charts do not allow for this, and all outside documentation will be scanned into an “outside records” section. It is important for the HUC to ensure that all scanned items are uploaded to the correct area so that clinicians do not miss important, time-sensitive information (Goodrum et al., 2020).

References

Goodrum, H., Roberts, K. & Bernstam, E. V. (2020). Automatic classification of scanned electronic health record documents. International journal of medical informatics, 144, 104302.