Health Information Management

Reduce record retrieval with accessible advance directives

HIM Connection, June 14, 2005

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Advance directives provide critical information about a patient's treatment wishes at times when every minute counts. At McAlester (OK) Regional Health Center, the registration staff routinely asked patients about advance directives.

Those who already had one on file with the facility would tell the registrar, who then called medical records staff to retrieve that record.

To cut down on those calls and retrievals, HIM Director Glennda Gore, RHIA, established a separate box where staff could store advance directives.

"Every time we saw an advance directive on a chart, we would make a copy and file it alphabetically in this box," she says. "Then when nursing or registration called, we would just go to the box rather than retrieve the whole record."

The advance directives box worked so well that Gore took it one step further. Now advance directives are scanned and put in a file on the network server. Nursing and social services staff--those who already have access to the facility's medical records--can access those advance directives from computers on the units.

Gore tried to initiate a process that would attach the advance directive to the Meditech electronic medical record, but that wasn't possible, at least not at a reasonable cost.

The directives are in the same network location as forms, policies and procedures, and other internal documents. By entering the patient's name, a nurse can see whether there is an advance directive on file and print it out, if necessary.

Response has been positive, Gore reports, adding that the clinical staff don't have to call medical records, and the medical records team no longer spends time searching for these records.

This excerpt is adapted from Medical Records Briefing.



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