Thinning Out the Chart for Scanning

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:

A 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.

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.

3 Comments

Click here to post a comment
   

Categories