How does one determine if a record is incomplete or delinquent?

18 05 2010

The University of Toledo defines an incomplete record as any record missing a required content, including history and physical, signed progress notes and signed physician’s orders, signed verbal orders, operative reports and discharge summaries.  They define delinquency as incomplete records that are over seven days old (Lynn et al).  For paper records, it is typically the duty of a records’ clerk to check patient records for completion once the files are returned (Healthcare Salary Online).  Those clerks would have to manually check the charts page by page to ensure that each were signed and completed (Tabbut).

Through the use of computer software programmes to store medical records, determining which records are incomplete or delinquent can be done with great ease.  Once a medical activity has taken place, the system automatically creates a need for a specific report, dependent upon the type of activity trigger, and until that report is completed and checked off in the computer, the file will continue to be flagged as deficient or delinquent (Simborg et al, 831).  In fact, some software systems can print reports by physician, department, days late, et cetera, for incomplete records (Meditech).


Work Cited

“Medical Records Clerk Job Description.” Healthcare Salary Online. Web. 16 May 2010. <http://www.healthcaresalaryonline.com/medical-records-clerk-job-description.html&gt;.

Lynn, Christopher K., and Ronald McGinnis. “Medical Record Delinquency Policy.” University of Toledo. Web. 15 May 2010. <http://www.utoledo.edu/policies/utmc/medical_staff/pdfs/3364-87-03%20Medical%20Record%20Delinquency%20Policy.pdf&gt;.

“MEDITECH – Medical Records.” MEDITECH – Medical Information Technology, Inc. Web. 16 May 2010. <http://www.meditech.com/ProductBriefs/pages/ProductBriefsCSMR.htm&gt;.

Simborg, Donald W., Marsha Shearer, Lydia Daniels, and Justin Moss. “A MEDICAL RECORDS DEPARTMENT SYSTEM — A VITAL NODE IN A HOSPITAL INFORMATION SYSTEM.” National Center for Biotechnology Information. University of California at San Francisco. Web. 15 May 2010. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2581343/pdf/procascamc00021-0853.pdf&gt;.

Tabbut, Byron. “EMR Fosters Eye Clinic Growth.” SRS Soft. Aug. 2008. Web. 15 May 2010. <http://docs.google.com/viewer?a=v&q=cache:cRXBa225pjwJ:srssoft.com/assets/files/WheatonCaseStudy_MDOptions.pdf+incomplete+medical+chart+would+be+returned+to+clerk&hl=en&gl=us&pid=bl&srcid=ADGEESh9Ac4nJLdEhZ7Fjoy2nz_JciSBzi7roMq9TPdWhY7ELtX0bgyC5j_LdXCjlyXf5ULfnaHAlNt2ro_YeVKcnbNmw2j54Lz68NPIot1dlC4Jy3lZBaIxPL769mnaVM1m61kemg5e&sig=AHIEtbTDQYddDfIuNdjbn2i8XrXlKGCqCg&gt;

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6 responses

29 09 2010
Eslinger

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9 02 2011
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10 02 2011
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10 02 2011
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11 02 2011
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30 06 2011
Carmen

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