I have been having great difficulty obtaining complete medical records from facilities that are using the EMR. I am not sure if anyone else is having this problem but if anyone has any potential solutions for formulating a records request that is comprehensive I would appreciate your input.
Here is just a sampling of the problems I have been encountering:
- Labs with no time only date
- No correspondence sent with the chart
- No orders sent
- Must specifically request written chart as well as EMR or they will not provide both
- No way to track the communication with the patient- telephone calls etc.
- Portions of an encounter but not the entire record
I know this is partly a problem because EMR is not meant to be read as paper there is much confusion on the part of the records retriever as to what belongs in the record. I can see hyperlinks to documents and am not getting those documents along with the record.
I have had numerous calls with the information management department and they have been generally unhelpful. My clients have sent letter - sometimes helpful. Some of my clients have had to file suit just to obtain all the records- and still have not gotten them all.
I have been including the audit trail with all initial requests and this has been a little helpful. I have seen a summary of records in one case but do not know how to ask for this.
Any suggestions? This problem is not isolated to one hospital but the great majority of it is. On site review is of no use in this situation because we can only verify that the hospital has everything they printed and not everything there is.