I’ve previously written about chart disposal after an EMR implementation and the concept of “thinning your paper chart for scanning into an EMR.” Because of those posts, one reader asked me about feedback on a list of what things should be included in the “thinned” paper chart.
Of course, my first reaction was to tell them to ask the doctors. Each doctor/specialty/clinic is unique and so every one of those would have their own list of what they thought was important. However, I also said I’d post their list on here for people to take a look at and provide feedback on things that shouldn’t be on the list or things that might be missing from this list. So, check out this list and I’d love to hear feedback on it in the comments:
Paper Chart to EMR Scanning List (in no particular order):
Birth records, Nursery, NICU, State Screen, Type/cross.
Growth Charts front and back.
Immunization record (multiples may exist, scan all).
Master Problem List.
All prior well child checks.
All acute visits if chronically ill, otherwise do not include uncomplicated CCD.
All special evaluations (ADHD/Feeding/Nutrition etc done in house).
All referral and specialists’ consults/findings.
Family History if known. Adoption may prohibit this.
City water vs well water.
Lab reports – baselines and all if chronic medical issues.
All diagnostic imaging reports.
Demographic sheet/all address changes.
All legal documents – custody/state/adoption/POA/living will etc.
A look at this list makes me think about what types of things might be useful when exchanging patient records electronically. Seems like the concept of thinning the chart and exchanging data might be worth considering together.