Where to put my notes?

  • 1.  Where to put my notes?

    Posted 10-15-2020 02:34 PM
    As CO, I field a lot of complaints that cross into multiple categories: For example, a patient might be upset about an interaction with a provider, but the conversation veers quickly from dissatisfaction to wanting a change in their Rx which then implicates care, possibly scheduling a new appointment, and sometimes even the provider's relationship with the patient.  Given that, would anyone be willing to share with me where they might place such a note after such a wide-ranging conversation?  I find myself constantly weighing need-to-know with patient privacy and plain old relevance, and I'm not always sure this should be something to put in a patient chart.

    Thank you to anyone who chimes in.  You all have no idea how much I depend on your insights!

    Adrianne M. Lara, MBA, CHC, CHPC
    Compliance Officer
    Cancer Care Northwest
    Spokane Valley, WA
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  • 2.  RE: Where to put my notes?

    Posted 10-15-2020 02:39 PM

    WE have a pt. complaints tab in our variance reporting system that allows us to upload any other relevant information. I would use something like this. The patient chart in not an appropriate place for all of that info.. Obviously if something happened while the pt. was in your care that needs to be factually noted such as a pt. fall or medication error etc. but all the follow up with staff and other investigation needs to be kept elsewhere.


    Thank you,

    Sharon Taylor, RN, MS, CIC, CPHRM, CHC, CHPC        

    Director Risk Management/ Accreditation Services

    Burgess Health Center

    1600 Diamond Street

    Onawa, IA 51040

    Tel: 712-423-9248

    Fax: 712-423-9322

    E-mail: staylor@burgesshc.org

    Website: www.burgesshc.org





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  • 3.  RE: Where to put my notes?

    Posted 10-16-2020 04:35 AM
    One of my responsibilities is helping to collaborate on overseeing Epic access. I personally wouldn't give a Compliance professional documentation access to an electronic health record system. That access is limited to clinical roles and other roles should be read only. I also wouldn't scan such a conversation in. If you were to document in a patient's EHR you may make things subject to the HIPAA amendment rules and if privileged they likely lose privilege. Also, employees have a right to privacy. I don't think it's appropriate to document complaints against them in an EHR where other staff may see them or where they are subject to release of information (ROI). Doing so opens up the organization to risk in my opinion.

    So where to document? Most organizations have a separate data base for risk management items and put compliance / privacy into that bucket or else the compliance office has its data base. Things to consider are a database that is a single source of truth for ease of administration (e.g., providing data to your board, responding to discovery etc., provides confidentiality, has role-based access limited to department staff or those who need to know for purposes of confidentiality and attorney client privilege when then may be asserted on certain documents meets and also meets retention requirements.

    Brenda Manning J.D., C.H.C., C.H.P.C.
    Privacy Director
    Privacy Officer
    Carilion Clinic

    The views expressed herein are my own and do not represent those of my employer. They are not meant to constitute legal advice or create an attorney-client relationship.

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  • 4.  RE: Where to put my notes?

    Posted 10-16-2020 10:47 AM

    I agree with Brenda! Well said!



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