HI305 Unit 7 Department Procedure Example

Moving a Page That Landed in the Wrong Chart: A Unit 7 Department Procedure for Correcting a Misfiled Scanned Document So Nobody Has to Ask Twice, With the Privacy Check It Triggers

[Student Name]

Purdue University Global

HI305: Management of Health Information

Unit 7 Department Procedure

[Instructor Name]

[Date]

The hospital, its systems and the procedure are composite; the regulations and sources cited are real.

Purpose

This procedure tells document imaging staff how to correct a scanned document that has been indexed to the wrong patient, the wrong encounter or the wrong document type. It exists because the task happens about twelve times a week, each specialist had been doing it slightly differently, and two corrections last quarter removed a document from the wrong record and left it filed nowhere. A written procedure makes the work the same each time and leaves a trail that shows what was moved and why (Oachs & Watters, 2020).

Scope

The procedure covers documents scanned by the department into the electronic health record. It does not cover documents created inside the record, such as typed notes, which the author corrects, or paper not yet scanned. It applies to all document imaging specialists, the quality analyst and the supervisor.

Roles

A document imaging specialist may move a document between encounters of the same patient and may correct a document type. Only the quality analyst or the supervisor may move a document from one patient's record to another patient's record. This limit exists because a move between patients changes who can see the information and may be a privacy incident.

Steps for a Move Within the Same Patient

Step 1: Confirm the error by opening the document and comparing its identifiers, date of service and content with the encounter where it is filed. Step 2: Find the correct encounter by matching the date of service on the document with the patient's encounters. Step 3: Use the reindex function to move the document. Never delete and rescan, because deletion breaks the link between the original image and its history. Step 4: Enter the reason in the correction comment, choosing from the list: wrong encounter, wrong document type, or other with a short note. Step 5: Record the correction in the department log with the date, the document identifier and your initials.

Steps for a Move Between Patients

Step 1: Stop and notify the quality analyst or the supervisor. Do not move the document yourself. Step 2: The analyst confirms the correct patient using at least two identifiers on the document, such as name and date of birth, plus the medical record number or the encounter barcode. Step 3: The analyst reindexes the page into the right chart and visit, then types the reason. Step 4: The analyst checks the access log for the wrong patient's record to see whether anyone opened the misfiled document while it was there. Step 5: The analyst reports the event to the privacy officer the same day, with the access log result. The privacy officer decides whether the event counts as a breach needing notice, applying the federal definition in 45 C.F.R. § 164.402. A page in the wrong chart is two problems at once. One patient's record is missing something, and another patient's record holds something that was never theirs to show.

Checking the Correction

The quality analyst reviews every move between patients and a random 10 percent of moves within a patient each week, opening the document in its new location and confirming the old location no longer holds it. Corrections that fail the check are returned to the person who made them with the reason.

Common Questions

What if the correct patient cannot be identified? Flag the document as unresolved, notify the supervisor and leave it where it is until the supervisor decides. Misfiled pages can at least be found by searching; unfiled ones may never surface again. What if the document belongs to another facility? It goes to the supervisor, who decides whether it is part of the hospital's record or should be returned. What if the physician has already signed a note that relies on the misfiled document? The supervisor tells the physician's office so the note can be reviewed. The imaging team does not change any note.

How the Procedure Was Tested

Before the procedure was adopted, the supervisor gave it to the newest specialist, who had never corrected a misfile, along with three composite misfiled documents in the training environment. She completed two without help and stopped correctly at the third, which belonged to another patient, and called the analyst. Her only question was where the correction log was kept, so the procedure now names the shared folder. The test took twenty minutes and showed the steps could be followed by someone who had not written them.

Why Write It Down

Before this procedure existed, specialists learned the task by asking whoever was nearby, and each person gave a slightly different answer. That is how two documents ended up filed nowhere. Patient identification errors in health records are a recognized safety problem, and the systems that support records can create new kinds of identification errors as well as prevent old ones (Ash et al., 2004). A procedure that is followed the same way every time is one of the few defenses that does not depend on any one person remembering.

References

Ash, J. S., Berg, M., & Coiera, E. (2004). Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. Journal of the American Medical Informatics Association, 11(2), 104-112. https://doi.org/10.1197/jamia.M1471

45 C.F.R. § 164.402 (2024).

Oachs, P. K., & Watters, A. L. (Eds.). (2020). Health information management: Concepts, principles, and practice (6th ed.). AHIMA Press.