Written: 5/84 Reviewed: 2/88; 2/90; 4/06 Revised: 2/87; 2/89; 2/91; 7/91; 5/92; 5/93; 2/96; 7/97;

7/99; 8/01; 7/04; 2/09; 1/12

Nursing Policy: C-43

LSUHSC-Shreveport, LA

______________________________________________________________________________ DISCHARGED PATIENTS' MEDICAL RECORDS PURPOSE: To define the guidelines for retrieval of discharged patients' Lite Chart from the nursing units to support continued communication needs. POLICY: 1. Accountability The medical record staff must account for all discharged patients medical records upon the patients discharge from the facility. 2. Placement Medical records (the current chart, thinned record portions, old chart and any incomplete charts) for patients discharged the previous day shall be placed in a designated area on each nursing unit prior to 0700 each day, Monday thru Friday. 3. Collection Health Information Management (HIM) department staff shall be responsible for collecting all of the patients medical record folders from the previous days discharges (current chart, thinned chart portions, old chart and any incomplete charts) from the nursing units beginning at 0700, Monday thru Friday. 4. Psychiatric Admissions and Discharges Regarding Inpatient Units For patients discharged from an inpatient unit to be admitted to the Psychiatric Unit; or discharged from the Psychiatric Unit to be admitted to an inpatient unit: a. Nursing unit staff will deliver Hybrid/ Lite Chart to the receiving unit along with the patient. When the patient is discharged from a medical/Surgical unit and readmitted to the Psychiatry Unit, the Lite Chart should follow the patient to the receiving unit.

b. Upon discharge from the facility all Hybrid/ Lite Charts will be picked up by the HIM staff from the unit the patient was discharged from.

5. Notification of Records Not Received a. The unit clerk shall be notified of all discharged patient's medical records not received by HIM department staff.

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b. The Assistant Hospital Administrator for Patient Care Services will be notified of any charts not received within a timely manner.

PROCEDURE: RESPONSIBLE ACTION PARTY Unit Secretary 1. Collects all discharged patients medical records (current chart, old chart, thinned charts, any incomplete charts, lab and x-ray reports, etc.) and ensures all appropriate documents are scanned into the medical record as the patients are discharged from the nursing unit; secures all this information together and places it in the designated location for the HIM department staff to pick up at 0700 hours the day following discharge, Monday thru Friday. HIM 2. Collects the charts of the previous days discharges from the nursing unit beginning at 0700 hours, Monday thru Friday. 3. Notifies the unit clerk of records not available while on the nursing unit. Unit Staff (where patient is housed) 4. For patients to be admitted to Psychiatric Unit where patient is housed immediately upon discharge from an inpatient unit, or to be admitted to an Inpatient unit upon discharge from Psychiatric Unit. Nursing unit staff will deliver Hybrid/Lite Chart to the receiving unit along with the patient. When the patient is discharged from a medical/surgical unit and readmitted to the Psychiatry Unit, the Lite Chart should follow the patient to the receiving unit. 5. Notifies the Assistant Administrator for Patient Care Services of all charts not received in a timely manner. 6. Assists in locating those medical records not received by HIM and notifies HIM of the location of the chart. Delivers to HIM those charts not available at the 0700 collection time.

HIM

Nursing Personnel

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________________________________________ Renee Lamb, RN Administrative Nursing Director for Medicine Services

_________________ Date

________________________________________ Jean DiGrazia, MBA, RN Assistant Hospital Administrator and CNO Patient Care Services

__________________ Date

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