In the chart prepping area of the Health Information Management...

In the chart prepping area of the Health Information Management (HIM) department of Rancho Regional Medical Center, the team worked quickly to process the chart of a patient that was recently discharged after a six-month visit. Because the patient was in the hospital for so long, the chart was large and had been thinned out multiple times. The process of thinning a chart occurs when HIM staff picks up portions of the chart and brings them to the department to await the final chart. This process occurs because the nursing stations are not equipped to house multiple stacks of paper.

While the team prepared the chart by removing staples, taping down loose items, and organizing the forms in logical order, they noticed that written progress notes from one entire month of the admission were missing. They knew they would need to find the missing progress notes because it is vital to ensure all chart components are present before releasing to the coding area. The team checked all stacks of progress notes, including all thinned sections and did not locate the progress notes. The team also made phone calls to the unit, but the nursing staff and unit clerk staff informed HIM that they had sent down all components of the chart and they were no longer on the unit.

Jerry, one of the senior HIM technicians, decided to visit the floor where the patient was admitted to search for the missing notes. Jerry had previous success with this tactic and decided it was worth the walk to the unit to search. When Jerry arrived on the unit, the staff quickly assured him that they had searched everywhere for the missing components. Jerry indicated that he understood but requested to look around a little bit more. The team on the unit agreed and continued on their way to care for patients.

Jerry opened several drawers and looked high and low in the nurses' station outside the patient's room. After about ten minutes of searching, Jerry located the missing progress notes. The missing section of the chart was tucked neatly inside a small drawer at the top of a cabinet. Jerry alerted the team that he did indeed locate the missing progress notes. The team thanked Jerry for his efforts and apologized for the oversight. When Jerry returned to the HIM department, he finished processing the chart and moved the prepped chart to the scanning area. The HIM team was thankful that Jerry took the extra steps to track down the missing components so that processing the chart was not delayed.

 

 

Do you think the patient care area searched diligently enough for the missing components?