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LNCtips.com: Hybrid Medical Records


Hybrid medical records are a combination of paper, scanned, and computer generated records.  With the advent of legislation that rewards healthcare providers who convert to electronic records (and punishes those who don't), hybrid medical charts are a new phenomenon for many healthcare providers.  Keeping paper records while incorporating new technologies produces cost savings for those who opt for a hybrid medical chart.  However, hybrid medical records pose some unique challenges for legal nurse consultants.

Computer generated records are designed to meet the needs of the users - doctors, nurses, medical assistants, financial staff, and administrators.  One of the challenges of these records is that they're not set up to meet the needs of the legal community.  When you add paper and scanned records to the mix, law firms need to be diligent in obtaining the complete legal chart.

I'm finding that records from physician offices and small outpatient centers are the most  problematic.  Hospitals and large healthcare organizations have used hybrid charts longer and have usually worked out the kinks.  In addition, large organizations have dedicated medical records departments that are used to producing complete medical records in response to legal authorizations and subpoenas.  Smaller organizations may not have any staff members trained in the storage and production of medical records.

I work in a defense law firm, and I find that with the advent of HMRs, it's difficult to explain the concept of a complete chartto these organizations.  Some clients produce only the paper medical records because that's the traditional version of a chart.  Some clients only produce the computer generated records because the paper medical records are in storage.

I've learned to go to my client's office and sit with the employee responsible for generating the chart.  Computerized medical records are usually organized by the patient's name, then by screens of each part of medical record.  The employee often skips some of the screens because "we don't use those."  However, they are still part of the HMRs and the client must produce them.

Sometimes two or more screens have similar information in different formats; the office must produce all of these.  For example, a client once sent my firm computer generated forms that medical assistants used for their documentation.  The forms contained the patient's height, weight, and vital signs but no dates or user name.  I learned that another form identified the date and the name of the medical assistant in addition to the height, weight, and vital signs.  I have since learned to look for a date and user name on computer generated records.  If there are none, there may be similar records that have the information.

When confronted with a potentially incomplete chart, I have also learned to ask the following: 

  • Do you still maintain paper medical records?
    • Are all the paper medical records maintained in the same place?
    • What about faxes, telephone messages, lab work, referrals, prescriptions, insurance forms, test results, authorizations, and pharmacy refill requests?  Sometimes offices maintain these records in a different part of the office.  When these records aren't contained in physical chart, staff members may not consider them part of the patient's medical records.
  • Do you scan any records? 
    • Which ones?
    • Where does the office keep them?
  • Do you have a computer generated chart? 
    • When did you start using it?
    • What screens do staff members use in day-to-day practice? 
    • Are there other screens available that link to the patient?

It also helps to create authorizations and subpoenas that explicitly list each part of the medical record.  However, many staff members have preconceived notions of what constitutes a complete chart and ignore the specifics listed on the authorization or subpoena.  In that case, LNCs can modify the above questions when following up on authorization requests or treater subpoenas.

Want to learn more about LNC skills for legal nurse consultants?  Check out the Archives.

...Katy Jones