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Written: 5/84 Nursing Policy: C-43Reviewed: 2/88; 2/90; 4/06 LSUHSC-Shreveport, LARevised: 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______________________________________________________________________________

DISCHARGED PATIENTS' MEDICAL RECORDS

PURPOSE:

To define the guidelines for retrieval of discharged patients' Lite Chartfrom the nursing units tosupport continued communication needs.

POLICY:

1. AccountabilityThe medical record staff must account for all discharged patients medical records upon thepatients discharge from the facility.

2. PlacementMedical records (the current chart, thinned record portions, old chart and any incompletecharts) for patients discharged the previous day shall be placed in a designated area on eachnursing unit prior to 0700 each day, Monday thru Friday.

3. CollectionHealth Information Management (HIM) department staff shall be responsible for collectingall 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 UnitsFor patients discharged from an inpatient unit to be admitted to the Psychiatric Unit; ordischarged from the Psychiatric Unit to be admitted to an inpatient unit:a.

b.

Nursing unit staff will deliver Hybrid/ Lite Chart to the receiving unit along with thepatient. When the patient is discharged from a medical/Surgical unit and readmitted tothe Psychiatry Unit, the Lite Chart should follow the patient to the receiving unit.

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

5. Notification of Records Not Receiveda. 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 ofany charts not received within a timely manner.

PROCEDURE:

RESPONSIBLEPARTY

ACTION

Unit Secretary 1. Collects all discharged patients medical records (current chart, old chart,thinned charts, any incomplete charts, lab and x-ray reports, etc.)andensures all appropriate documents are scanned into the medical record asthe patients are discharged from the nursing unit; secures all thisinformation together and places it in the designated location for the HIMdepartment 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 unitbeginning at 0700 hours, Monday thru Friday.

3. Notifies the unit clerk of records not available while on the nursing unit.

Unit Staff(where patient ishoused)

4. For patients to be admitted to Psychiatric Unit where patient is housedimmediately upon discharge from an inpatient unit, or to be admitted toan Inpatient unit upon discharge from Psychiatric Unit.Nursing unit staff will deliver Hybrid/Lite Chart to the receiving unitalong with the patient. When the patient is discharged from amedical/surgical unit and readmitted to the Psychiatry Unit, the Lite

Chart should follow the patient to the receiving unit.

HIM 5. Notifies the Assistant Administrator for Patient Care Services of allcharts not received in a timely manner.

NursingPersonnel

6. Assists in locating those medical records not received by HIM andnotifies HIM of the location of the chart. Delivers to HIM those chartsnot available at the 0700 collection time.

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________________________________________ _________________Renee Lamb, RN DateAdministrative Nursing Director forMedicine Services

________________________________________ __________________

Jean DiGrazia, MBA, RN DateAssistant Hospital Administrator and CNOPatient Care Services