New Patient Added
When there is a new admit, the documents are filled out and/or signed. During the patient's stay at the facility, many more documents are added to the record, such as: history and physical, progress reports, consult reports, medication lists, prescription orders, laboratory, x-rays, diagnosis lists, occupational/physical/speech therapy documents, documentation from previous hospital stays, and more, depending on how intensive the treatment is.
Medical Chart Thinning
When patients stay at the facility for over 3 months, their charts start need to be thinned. So the records are taken one at a time, and many areas need to be thinned out by taking out documents with dates over 3 months old. They are then taken put in the long-term overflow file cabinet. Some of the thinned areas include medication records (MARs) and treatment records (TARs), consults and progress notes, and laboratory results.
Patient Discharged
After patients are discharged, their medical records are sent down to the medical records department. They are then broken down and condensed into a smaller folder (or several, if the patient had a long stay) to store them. The sections of the record at this point include: Face Sheet (Record of Admission), advance directives, MDS assessment, care plan, history and physical (h&p), physician's orders, progress notes, nurses assistant notes, lab and special reports, rehab and therapy, social services, dietary, activities, legal and misc., and the discharge checklist.
*Note* Every time a patient is discharged and then readmitted they will have a new medical record compiled, but will keep the same medical record number.
Record Stored
Every year, the medical records from previous years are moved to the storage room. Usually, records can be destroyed after 7 years. However, there is a lawsuit going on with a hospital, and until the lawsuit is settled, the records cannot be destroyed. This is very frustrating because the facility is running out of storage room.
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