- Why does my medical record not contain everything that happened to me during my stay?
- Why does this version of my record not look like the previous version that you provided to my lawyer?
- Why does the record you gave me last month look completely different from the record you gave me last week?
- Why does my medical record have no rhyme or reason to its order? It’s so hard to understand!
Have you ever found yourself fielding these sort of questions? Do you have a difficult time explaining what constitutes your Legal Medical Record (LMR) and Designated Record Set? Do you see inconsistencies in what information is released from your organization? If so, The Wilshire Group can help!
Wilshire has experienced Epic certified HIM consultants and HIM operational personnel that can assist with answering these difficult questions. We all know that the implementation of an EHR is a critical pillar to healthcare delivery and an organization’s success, but it requires detailed knowledge of the system’s capabilities. Although EHRs allow a healthcare organization to store vast amounts of clinical data, it can sometimes seem impossible to get that information out of the system and into a meaningful format. Add on government regulations, HIPAA/HITECH constraints, coding requirements, system updates and upgrades, altering workflows…You find yourself struggling to confidently say what is contained in your LMR.
At Wilshire, we can provide a framework for reviewing your current LMR, develop an index to thoroughly document your LMR’s content, and establish maintenance and update policies & procedures to help you feel confident in the integrity of your LMR.
Let us share our expertise to ensure that your LMR is accurate, reproducible, and consistent. For more information, visit our website or contact Jennifer Esterbrooks (Director of Health Information Services).