Medical Record Roulette

Just run that patient chart through the copy machine, and put it in the mail, right?


Many, if not most, health care providers still keep a paper folder for paper documents with patient signatures, but even if they have scanned the original chart for digital storage, analysis of those “wet” ink signatures might confirm the date signed in a legal dispute.

In addition to all that paper, evolving  technologies have left most providers with a complex trail of digital medical record files in a variety of formats on a variety of media, local and in the cloud. Some may require software or hardware no longer supported by vendors and no longer in the possession of the provider.

Contact management software, local or in the cloud, may contain patient contact information. Word processing software may contain evaluations and progress notes. Account information and prescribing logs may exist on spreadsheet software, locally or on a Google server somewhere. An electronic medical record (EMR) might store audio files. Try to “print” one of those on paper.

How will you find, much less reproduce and transmit, prescribing records from an eprescribing service no longer used, or a now defunct EMR?

Even if you find all the records, and the software to open all the files, you cannot determine the completeness of a “copy.” Just hope your provider does not assume otherwise when making life or death decisions about your care.

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