The Medical Records Minefield

by Flora Bessey, Pharm.D., BCGP

What do you know about the medical records department? How often do you interact with them? Do you see them only once every three months, at the quarterly meeting? To you, are they the annoying people that are always bugging you to sign documents? Do you appreciate how vital they are?

The medical records departments of our facilities are often misunderstood and underappreciated, yet they fulfill many incredibly important needs. And having a well-functioning and highly-trained medical records staff will lead to much better resident outcomes, as well as better performance on survey.

When attempting to ascertain the “health” of your medical records department, it is very helpful to know exactly how they are doing their main job: maintaining records. In the early 2000’s, CMS “encouraged” (but still has not enforced) that all nursing homes maintain the resident health records electronically, aka “electronic medical records” (EMR). Various software companies rushed to fill this need, and several programs quickly became the most common, among them PointClickCare (PCC) and Matrix. Predictably, the implementation of the CMS “direction” was a bell-shaped curve, with some facilities diving right in and fully converting to EMR, other facilities refusing to change at all (“if it’s not broken, why fix it?”), and most falling somewhere in the middle, doing a slower (in some cases, years-long) “transition” from paper charts to EMR. The reasons for the foot-dragging will probably sound familiar to you: the hardware and software is too expensive; it’s too hard to pull nurses off the floor to train them, and why should we train them when turnover is so high?

So, which system is in use in your facility? Is it fully EMR, hybrid EMR and paper, or paper-only? This is very important to know, since it affects how you do your own documentation. With EMR, you can just enter med orders, labs, notes, etc. directly into the patient chart (or a nurse can do so in the case of a telephone order). Even in buildings that are fully EMR, there is usually a paper “chart” (more like a binder) that acts as a “placeholder” for paper documentation that has yet to be entered into the EMR (like lab results, hospice notes, etc.).

If your facility is “old school,” and uses only paper, you may notice that you are developing back and shoulder pain from lugging around the enormous charts (they have to maintain months and months of complete MDS data, after all). You may also notice that the filing system within the chart can be, at times, haphazard (to put it kindly). As much as we occasionally complain about CMS, the reasoning behind the push for EMR is sound: paper charting is slow, and cumbersome, and often prone to errors (reading the handwriting of a NOC-shift nurse on the pink copy of an NCR can be a challenge). If you are the medical director at such a facility, you can help drag them into this millennium.

Then there are the many “hybrid” facilities. These present their own challenge. What goes in the paper chart, and what goes in EMR? Where do you do YOUR documentation? How do we ensure nothing is missed? When does MDS enter their data into the system? Where are labs captured? 

Speaking of labs, this brings up an important point: how are labs ordered? Is your medical records department auditing labs daily? One idea I have heard proposed, but so far never implemented: have medical records at stand-up every morning to discuss lab orders and results!

In conclusion, it would behoove you to pick a charting system and stick with it. If your building just refuses to move away from paper, make sure systems are in place to minimize the (inevitable) errors. If you are in a “hybrid” building, encourage the full transition to EMR as soon as possible. You can help by leading by example: do all of your orders, charting and notes directly into the facility’s EMR system.

So, get to know your medical records department. They are a vital link in the chain of patient care, and an important part of maintaining your building’s CMS compliance.