March 23, 2006
Thinning Out the Chart for Scanning
Written by: John
I saw someone give a great idea about which part of the chart should be scanned into your EMR. I should do some more posting on how, what, when to scan into an EMR when implementing an EMR, but that will just have to wait. Until then, this might be a good idea to look at.
Here’s what was said in the original post:
Related ArticlesA very common practice when a paper chart gets too thick is to ask a physician or nurse to “thin out the chart”. You are basically asking the clinician to select the important paperwork in the chart necessary to continue to take care of the patient. Typically a thinned out chart should include all of the patients clinical history ie PMH, FH, SH, Meds, Allergies, etc -this information you would find in the most recent H & P. Also drs and nurses also like to have the latest labs, X-rays, EKG, and other diagnostic studies as well as previous ones that were abnormal. There is no need to enter or even scan in years of normal UA’s, normal throat cultures, etc. All of those normal results (except for the most recent one) can all be put away in the paper chart. Remember in most states paper charts still need to be kept for about 7 years.
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[...] those that feel they need to see a past chart, you might consider my previous post about “Thinning Out the Chart for Scanning to an EMR.” The idea is just pulling out the relevant information that needs to be inputed into the [...]
[...] Archiving or Shredding Old Paper Charts One of the big questions people ask is what do we do with the old paper charts. In this post I’m not going to talk about the various ways that you can incorporate your old paper charts into your EMR workflow. I’ve covered that a number of times before including my post about thinning your paper chart. [...]