The integrity of medical records is a critical component to patient safety.
We need to ensure that each document type is located in the correct area of the chart. A correctly arranged chart is an accurate chart.
Lately we’ve seen more of these files in the wrong locations: History & Physicals, Discharge Summaries and Op Notes.
They belong in their own sections. Here’s a tip: If you create your note by following the link in your InBasket, the documents will file in the right location!
If the documents are filed elsewhere, HIM has to go in behind the scenes to relocate them so that accurate releases of information and transfers of care can occur.
Questions? Contact our Data Integrity Specialist at 503-814-2737.