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Delinquent medical record enforcement resumes

13 Sep 2020

Electronic notices will improve; starts Sept. 21



By: Mathew Boles, MD, vice president of medical affairs

The Medical Staff Office began enforcing rules and regulations on Oct. 1, 2019, which involved fining providers who have not completed medical records. As a reminder, medical record completion is essential for patient safety; it also finalizes the patient record for billable services. 

At the beginning of the COVID-19 pandemic, however, enforcement was paused to allow for more urgent planning.

The health information management department and the MSO discussed resuming this process as incomplete records not only place our patients at risk, but threaten regulatory compliance and can create patient encounters that are not billable.

To achieve this objective, please note the following:

  • Starting Sept. 21, 2020, the MSO resume enforcing the medical staff rules and regulations in full, including fines. 
  • Please know that the HIM process of sending electronic warnings in Epic is still in place, and is designed to give providers time to complete medical records and orders prior to fining due to delinquency. Based on provider feedback we have made several editorial changes to make the notifications more intuitive and streamlined. 
  • If you have any questions or concerns regarding incomplete records, please contact Christine Jackson in HIM directly at Christine.Jackson@salemhealth.org or 503-814-2742. 

To ensure readiness, please note the following:

  • If you are planning an absence for one week or longer, be sure to reach out to the MSO at 503-814-3889 or HIM at 503-814-2742 as they will place your incomplete records on hold during the time you are away. You can also email your absence to MedicalStaffOffice@salemhealth.org or HIMRecordintegrity@salemhealth.org
  • Since we are moving to electronic communication, please be sure the MSO has your preferred email on file. Additionally, you may supply the MSO with one additional email address which will be cc’d on the email correspondence (manager, office assistant, medical assistant, etc.) .
On behalf of the medical executive committee, HIM and with the support of the physician leadership council, I want to thank you in advance for your commitment to medical record completion. Should you have any questions, please feel free to reach out to your section chief or contact Dr. Matt Boles in the MSO at 503-814-3216 or Matthew.Boles@salemhealth.org