Paper Disposition at Skyline Family Practice
| Disposition of paper that comes into the practice is critical for several reasons: | |
| - | Paper related to patients affects their care directly |
| - | Paper takes time to process |
| - | Paper takes up precious space |
| It is our goal to reduce paper as much as possible at Skyline Family Practice. This policy may change with time as we get better at this! A "chain of custody" is important to processing paper: | |
| - | Many forms of paper require physician review and action critical to patient care |
| - | Once action has been taken and the paper has acted upon and entered into the electronic chart, it is destroyed |
| - | It is very important for the person in the chain of custody to make sure the prior person has initialed off the paper!! |
| Type of Incoming Paper |
MD |
Where in EMR | Disposition (Chain of Custody) | Who? |
| ER Reports | Y | Progress Notes (use Template for entry) | MD->ST->PAC->30d Folder | MD,ST,Billing |
| X-Rays | Y | Xrays/Special Studies | MD->N->ST->30 D Folder | MD,N,ST, FRT |
| Procedure Notes | Y | Procedures | MD->ST-> 30D Folder | MD,ST,FRT |
| Special Studies | Y | Special Studies | MD->N->ST->30D Folder | MD,N,ST |
| IMMUNIZATIONS | N (since direct order) | INJECTIONS/IMMUNIZATIONS | MD(order)->N(input) | MD,N |
| Consults | Y | Consults | MD->Nurse (action)->ST->30d Folder | MD, Nurse, ST |
| Admission H&P's / Discharge Summaries | Y | Discharge Summaries | MD->ST->30D Folder | MD->ST |
| Other Faxed Reports/Info | Y (if directed) | Depends (to ST if needed) | MD (or other staff)->30d Folder | All |
| Laboratory Values | ||||
| PML Labs | Y | Lab VIA INTERFACE | Send Normal Letter -
NURSE TO GENERATE -
MD TO SIGN SIGN RE: LETTERS |
MD, Nurse |
| Problems: different modes of communication patients calling back patient expectations of call back | N to call | MD, Nurse | ||
| MD to call | MD, Nurse | |||
| MD->Nurse->30d Folder->Discard | MD, Nurse | |||
| Non-PML lab | Y | MD->Nurse?->30d Folder->Discard | MD, Nurse | |
| In house - CBC, U/A | Y | Lab (logged) | MD->Nurse?->30d Folder | MD, Nurse |
| Hospital Lab / Other Lab | Y | Lab | MD to decide if logged and may discard ->Nurse to log (possibly act on this)->30d Folder | MD, Nurse? |
| OLD Medical Records from Other Doctors | Disposition depends on Items | |||
| Progress Notes | Y | MD may elect to discard medically worthless information | PAPER Chart not Discarded | MD, Nurse |
| old records are never discarded BY ANY STAFF (OTHER THAN THE MD); unless the patient doesn't want them. The patient will be called by FRT staff and asked if they want the information | ||||
| Admission H&P's, Discharges | Y | MD may direct FRT file or --> | MD->ST | MD, FRT, ST |
| Labs | Y | MD may discard* - other wise | MD->N | MD, N |
| IMMUNIZATIONS | Y | INJECTIONS/IMMUNIZATIONS & HEALTH
MAINTENANCE Nurse must enter both SAVE OLD SHEET |
NOT DISCARDED | |
| Consent Forms | Y | Paper Chart->?future Section | NURSE/Patient -> MD->Paper Chart | MD,N,FRT |
| Living Wills/DPOA/AMD | Y | Paper Chart->?future | MD->FRT | MD, FRT |
| Demographic Info | N | Some in paper | FRT | FRT |
| Truth-in-Lending statement | N | Paper Chart | FRT | FRT |
| EKG (outside) | Y | EKG | MD->ST (notation in EKG section) | MD,ST |
| EKG (Brentwood) | Y (includes pre-ops) | EKG (Typed by MD) | Disposal immediately or
given to patient NOTE: MD must review first |
MD,N |
| KEY to Personnel |
| MD = Physician |
| N = Nurse |
| ST = Scanning technician |
| FRT=Front Office Staff |