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Completing The Electronic Medical Record After Discharge
(For Medical Staff Only )

Introduction

Date of Last Review 6/7/07
SME:
Director of Health Information Management

Purpose: All physicians have the capability of updating and completing the patient's medical record on line from any computer in the hospital.

Procedure:

Health Information Management (HIM) will place a deficient/delinquent list of medical records in each. physician's mail box weekly.
From the deficient/delinquent list the physician's can update the electronic medical record.
If the physicians update the record at a computer other than the computer in HIM, HIM needs to be notified about the patient updates.
The list can be returned to HIM with a check by the names of the patients who had updates.
HIM staff will use this returned list to update the physician's deficient/delinquent list in this system.

 

Related standard

HIPAA : Privacy

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Harris County Psychiatric Center University of Texas Health Science Center