The director of health information management, as the custodian of medical records, is having a great deal of difficulty responding to subpoenas for patient records. The facility is in the midst of converting from a paper-based to an electronic patient record. Some information is on paper (such as consents), some information is scanned immediately following discharge (such as nurses’ notes), some information is automatically (COLD) fed into the EHR system (such as transcription reports) and some information resides within electronic systems (such as lab results and physician orders). The process of finding and identifying the various parts of the patient’s record from the various sources is time-consuming and there is concern about insuring the same response (that is, that the legal health record is produced) each time a record is requested. An attorney requested a record, followed by an additional request. What he received from the organization the first time was substantially different from what he received the second time. When the attorney deposed the custodian, many questions were raised about how record requests were handled, daily operational processes including how the patient’s legal health record was compiled in response to this subpoena, and if this was the true and complete record for the patient. What steps should the director take to assure that responses to subpoenas (that is, the legal health record) consist of the same information? Research Explore the Joint Commission website (www.jointcommission.org) with the specific goal of identifying information pertaining to permissible and prohibited abbreviations. In your summary, explain which abbreviations are permissible and which are prohibited according to the Joint Commission. Students should be able to explain why the abbreviations on the “do not use” list have been barred.
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