Where are the patient records I need?

eHealth Technologies blog: Michelle Donowsky, RT (T), Executive Director of Clinical Optimization, eHealth Technologies

In order to have a meaningful and thorough first visit with a referred patient, it is important to have all of the pertinent records and images necessary to assess and create an effective treatment plan.  There are many factors that can impact the availability of records at the time of appointment:

  • No records received due to copy services or delay from providers.
  • Partial records are available at visit, but critical results like molecular/genetic, comparison radiology or specialty consult reports are missing.
  • When relying on the patient to procure their own records and images, a lot is left to chance. Incomplete record sets can show up with the patient on the day of appointment. Reports and images that reference their latest knee replacement are not very helpful in their breast cancer treatment plan.

While it may be impossible to control all of the factors that go into record acquisition, there are ways in which we can more proactively request the “right” records and images.  Below is an excerpt from a typical Oncology Intake/Records Request form:

One of my first observations when I started working with clinicians on record retrieval was that the formatting and content of the record request was often times too vague and muddled. This contributes to frustration around the records received and sometimes more importantly, the records that are not present. When I probed many clinicians further and asked specifics about which records were being requested by their staff, it became clear that there were some very large gaps.

When sending a request like the one above, you are leaving too much for the provider’s staff or medical records department to decipher. This leads to missing records. It is extremely important to be as specific as possible. You will note that both Breast Cancer and Neuro Cancer fall under Oncology, but the records and images the physicians would need to review are vastly different. Knowing exactly which records are needed, and from what time range, is critical to prepare for the first appointment. (See examples below.)

At eHealth Technologies, not only do we remove the burden of record acquisition from your patients and reduce the amount of time it takes your staff to chase down and organize records and images, we also work with you prior to launch to ensure you’re asking for the precise records you need to assess your patients. We work with your intake staff and clinicians to build templates for records specific to disease type, stage, provider type (Hospital, MD Office, Dialysis Center, etc.) and physician preference.  We also provide you with the disease specific “Gold Standard” templates we have created with world-renowned institutions.  Given these as a starting point, typically only minor edits need to be made to meet your unique needs.

We are very proud of our ability to reduce the time it takes to get records, remove the burden from patients and staff, all while ensuring that you are getting the “right” records you need for a meaningful first appointment.