Flow Chart Medical Record

							This month’s form

Editor’s note: The following is an actual form the Albany Medical Center’s patient access team
used as part of its policy and procedure:

Albany Medical Center                                            Policy & Procedure 8.39
Department of Patient Access                                     Unit: Emergency Department
Division of Corporate Finance
Effective: 1/25/05
Revised: 3/9/05; 8/12/05; 12/28/05; 2/14/06; 3/15/06;
         5/19/06; 6/6/06; 6/22/06; 12/19/06; 4/30/07; 6/15/07; 3/10/08

Subject: Chart Flow

Purpose: To ensure a patient medical record is completed and accounted for throughout their visit in the
         Emergency Department and the management of charts for expirations.

Billing Impact: Lack of patient medical record could impact receiving payment from insurance payer or
                cause provider fault

Procedure:

Patient enters the Emergency Department through triage/EMS; an Invision quick registration is completed
and the medical record is created and placed in binder.
All forms pre-stocked within the record (excluding back pocket) will be labeled with a patient label.
Each page of multiple paged forms must have a label placed on them

When the patient is physically placed in a room in the department, the medical record is placed in the
proper slot in the appropriate zone.

All documents are to be filed into the binder by the clinical staff member caring for the patient as
documents are completed during the patient’s visit; the chart dividers identify the location of forms.
The patient advance directives are to be filed into the identified red sleeve inside patient department chart
binder by either clerical or clinical staff

Upon discharge, the physician prints their name and discharge diagnosis on the medical record.

The medical record is forwarded to the respective zone clerical staff to discharge from Invision.

The clerical staff member reviews the record for completion. If the attending physician signature is not
present on the record, the zone clerical staff member will complete the “record completion form”
(Attachment 1) and indicate as such.

All discharged records will be sorted by attending physician and roughly alphabetized (all A’s together,
all B’s together, etc…) within that attending
All medical records will remain at the clerical zone support desk until the close of that clerical zone desk
(2am for the A/D-zones).

At the closing of the desks, the B zone and C zone records will be reviewed.
For any physician no longer present in the department the charts will be brought to registration and sorted
by physician in alphabetical order. A red slash will be placed on the record.
At the end of the night shift, all records will be married to the records in registration and records will be
filed in the designated bin, by physician.

If the patient is transferred to an inpatient floor, the entire medical record will go with the patient.
The zone clerical associate will review the medical record for completeness - Admission Order, Attending
Physician Signature, and Diagnosis.
If the record is incomplete, the zone clerical associate will forward to charge nurse to obtain missing
information.
Once the record has been reviewed for completeness, the zone clerical staff member will empty the record
from the department binder and forward it to the primary RN of the patient.

Upon discharge from the Emergency Room, the medical record will be burst in the chart dividers dictated
order.

For all expirations, the chart will be given to the zone clerical associate, 1 copy of the medical record will
be made and discharged out of Invision.
A copy will be given to the charge nurse to be taken to the morgue.
Original chart will be placed in documentation specialist’s bin.
Bed Access will receive the pink copy of the Death Notice.




Associated Policy and Procedure:
#8.40 Assembling of Patient Binders


Authored: Jamey Castiglione
Approved: Cathy Pallozzi
Last reviewed date: 3/10/08
Attachment 1
 Policy 8.39