Welcome to EMR and HIPAA

I was approached the other day by my HIM (medical records) staff with a sheet of paper asking me to find which patient it belonged to.

Yes, unfortunately we have an electronic medical record with as little paper as possible, but you are always going to have papers floating around. Even with EMR you can’t stop patients from bringing in paper to you which you are then responsible to keep. Good thing you can at least scan the paper. Scanning is definitely worthy of another post though.

So, here I was charged to find which patient this stray sheet of paper belonged to. This paper had no identifying information for the patient (Don’t ask me how that happened). The only information that could really be gleaned from it was which doctor had seen the patient, the patient was a nursing student and that the patient was pregnant. Now many of you may be saying, well having many nursing student patients do you have which are pregnant? This is a valid question, but all those people balking at my example take a step back and imagine you didn’t have an electronic medical record. How would you find this patient?

Charts..
Charts..
More Charts!

Is there really anything else that could be done besides sifting through chart after chart? I can’t really think of much.

With an EMR it was no problem finding whose chart it must be. I pulled up all patients with a pregnancy diagnosis for that doctor and then looked for the patients that were in the nursing school. Patient Found!!

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