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2.15.2 Medical Records, Shadow Records and Medical Media

A. Purpose

To ensure a single unit medical record is comprised of all appropriate medical data generated on each individual University patient for continuity of patient care and legal purposes.

B. Persons Affected

All University of Texas at Tyler (UT Tyler) and the University of Texas at Tyler Health Science Center (UTTHSC), including off-campus instructional sites, (collectively the “University”) faculty, staff, students, volunteers, and any contractors or agents granted access to confidential information.

C. Definitions

  1. Unit Medical Record (UMR): The official University medical record maintained by the Department of Health Information Management (HIM) that contains the University's original patient care documents in either electronic and/or paper form.  The paper portion of UMR is designed to contain the written interpretations of all significant clinical information gathered for a given patient, whether as an inpatient, outpatient, or emergency care patient.  The entire patient's medical record is in one volume, or multiple volumes, under one hospital number.  UMRs have a permanent retention schedule.
  2. Subsidiary Medical Record (SMR):  A medical record maintained by a specific department other than HIM, which contains original paper and/or electronic records concerning outpatient health care administered by health care providers to University patients.
  3. Shadow Record (SR):  The medical record maintained by a specific physician or department, other than HIM, that includes patient care information also included in the UMR. SR include copies of medical record information also in the UMR. SR should not contain any pertinent patient care information that cannot be found in the UMR. SR is considered a convenience copy and has no record retention schedule. SR will not be removed from its location of origin, and PHI may not be released from SR.
  4. Medical Media: Medical Media includes health information stored in any original media.  Examples of Medical Media include, but are not limited to, x-rays, videotapes, ultrasounds, photographs (either conventional photos or digital images) and EKG strips.  These forms of Medical Media have unique retention schedules.  UMR must contain a written or electronic interpretation of all Medical Media.  Medical Media is distinct from the written interpretations of significant clinical information that has been forwarded to UMR.  Medical Media originals remain in their location of origin except for archiving according to the record retention schedule.
  5. Designated Record Set: A group of records maintained by or for the University that are:
    1. The medical records and billing records about patients maintained by or for the University;
    2. The enrollment, payments, claims adjudication, and case or medical management record systems maintained by or for a health plan; or
    3. Used, in whole or in part, by or for the University to make decisions about patients.

D. Policy and Procedures

Unit Medical Record (UMR)

A UMR shall be generated for each University patient, and HIM or designated clinics will maintain all UMRs.

  1.  All pertinent non electronic University health care information created is to be documented on approved medical record forms.  All proposed forms must be approved according to guidelines in Medical Records Forms Management.
  2. Patient name and unit medical record number (UMR#) are to be clearly printed or included on a label attached to each page of the medical information.
  3. Any University personnel who uses UMR must ensure that PHI is maintained confidentially and must use only the minimum necessary amount of information required to complete the person's tasks.
  4. No one other than HIM can disclose information from UMR, for purposes other than Treatment, Payment, or Health Care Operations (TPO).  Departments must forward non-TPO requests for PHI to HIM for processing.

Medical Media

Medical Media refers to original information in any format that is used as a basis of diagnostic test or report. The original interpretation of the Medical Media data must be stored in UMR.  Medical Media must be maintained in a manner that ensures the confidentiality of PHI in accordance with The Joint Commission (TJC) standards on medical record services, University policies and procedures, and applicable federal and state laws.

Subsidiary Medical Record (SMR)/Shadow Records (SR)

Health care information in the form of SR must be maintained as follows:

  1. SRs must be maintained in a manner that ensures the confidentiality of PHI in accordance with TJC standards on medical record services, University policies and procedures, and applicable federal and state laws, specifically including HIPAA regulations.
  2. Any and all requests for the release of PHI must be referred to HIM.  PHI will not be disclosed from SRs.
  3. If SRs are found to contain original medical information that should be in UMR, the information must be removed and incorporated into UMR immediately.
  4. When SR is no longer needed, the SR must be disposed of in a manner that ensures the confidentiality of PHI (see IHOP Disposal of PHI).
  5. SMRs must be retained according to UMR retention policy.

Physical Management of Medical Records and Scanning to EHR

Any University department or clinic that maintains SMRs, SRs, Medical Media or copies of medical records must designate a Record Custodian responsible for compliance with this policy. Record Custodians must take appropriate measures to ensure UMRs, SRs, SMRs and Medical Media are maintained in a secure location with restricted access.

Record Custodians must also ensure that approved paper documents are properly scanned to the University's electronic health record (EHR) as follows:

  1.  Approved paper records will be scanned into EHR by HIM, Patient Access and clinical and ancillary departments. 
  2. Scanned electronic images of approved paper records become UMR immediately upon creation.
  3. Approved paper records are listed on the Master EHR Document Scanning List maintained by HIM (see Attachment A). If a classification does not exist for the document proposed for scanning, the Records Custodian contact HIM to establish an appropriate classification for the proposed document.  HIM will present new documents proposed for scanning to EHR Leadership Committee for final approval.
  4. Unauthorized scanning into EHR may result in disciplinary action. See Attachment B, EHR Document Scanning Procedure, for further information.

Release of Information

HIM will be responsible for the release of any information for purposes other than TPO, including, but not limited to, information that requires patient authorization or information requests pursuant to subpoenas or court orders.

Enforcement 

Violation of this policy may result in disciplinary action that may include termination for employees and temporaries; a termination of employment relations in the case of contractors or consultants; dismissal for interns and volunteers; or suspension or expulsion in the case of a student. Additionally, individuals are subject to loss of University Information Resources access privileges, civil, and criminal prosecution.

E. Responsibilities

See section D, Policies and Procedures.

F. Review

October 2022 by UT Tyler leadership

G. References

Federal and State Privacy laws including:

HIPAA - Health Insurance Portability and Accountability Act;

HITECH Act (42 USC §17921 et. seq.)

Texas Administrative Code 202.70;

UTS-165 UT System Information Resources Use and Security Policy 

 

ATTACHMENT B - EHR Document Scanning Procedure

Documents submitted for scanning into EHR must follow the policy for scanning into the HER.

All appropriate medical documents that are prepared for incorporation into the official University medical record (UMR) must contain complete and legible patient identification data, i.e., patient name and complete University medical record number.

Documents that should not be scanned into EHR:

  • Printouts from University computer systems (Epic, Aria, etc.)
  • Duplicate copies
  • Demographic sheets
  • Fax sheets
  • Unapproved documents

Outside medical records submitted for scanning must be reviewed and/or approved by the responsible clinician as indicated by the clinician's signature on the paper document (first page only if more than one page).

Outpatient clinical documents should be scanned within 72 hours of document receipt in HIM. There may be specific document types that require scanning within 24 hours of receipt. These requirements must be specified by the managing department with the agreement of HIM. Documents not otherwise specified should be scanned within 72 hours from the date of service.

Correspondence for patient care will be limited to what is medically necessary. Fax sheets and demographic pages will be removed prior to scanning.

Quality reviews on scanned documents are completed by HIM. Scanning permission may be revoked if an excessive errors are found or if other inappropriate scanning practices are discovered.

When ambulatory scanning errors are identified, the scanner and his/her supervisor will be notified. The document management system allows scanned documents to be "removed." A document is "removed" if it was scanned to the incorrect patient or document type. The "removed" document will be available under the "Maintain Removed External Documents" tab in APR.

Occupational Health records may be scanned into a separate electronic system.  Occupational health document types appropriate for scanning are determined by Occupational Health personnel in consultation with HIM.   

Inquiries about scanning should be directed to HIM.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPROVED: 10/26/22