An Ordered Universe One Chart at a Time

Vol. 15 •Issue 9 • Page 18
An Ordered Universe One Chart at a Time

In the paper world, universal chart order is an efficient, time saving practice for maintaining medical records. Has the electronic age rendered this system obsolete?

Oscar Wilde said that consistency is the last refuge for the unimaginative. Wilde obviously did not work in health care, especially in HIM where nothing should be left to the imagination when it comes to assembling and retrieving patient information from the chart. But is universal chart order still practiced as vigilantly today in HIM departments given the health care industry’s momentum toward the electronic health record (EHR)?

The Order of Things

“Chart order, and universal chart order in particular, has been an HIM best practice for a number of years,” explained Beth Hjort, professional practice manager for the American Health Information Management Association (AHIMA). “The concept behind universal chart order is efficient, user-friendly, cost-effective information availability to medical record users through a standardized record arrangement.”

Consider an HIM best practices study conducted by Oakbrook, IL-based University HealthSystem Consortium (UHC) back in 1999. “Using a standardized format for hospital records is associated with faster record completion times,” wrote Danielle Carrier, program director in operations improvement at UHC. “Implementing a universal chart order used by both the hospital inpatient units and the medical records department eliminates reassembly time by medical records staff.” After implementing such a system, Both University of Kansas Hospital and the University of Utah Hospitals and Clinics were able to reduce staff and cut record completion time by 1 day (see Journal of AHIMA 70/7, 1999).

The Origin of the Universe

“I would say that roughly 75 percent of hospitals have the same chart order,” observed Dan W. Stober, national sales manager for EDCO—The Document People, Springfield, MO. Stober attributes the consistency to past JCAHO standards.

“JCAHO’s 2005 standards, now less prescriptive than in past years, do not specifically require hospitals to have an established chart order, but rather leave mechanisms up to the organizations to ensure the ‘information found in the patient record [is] organized for efficient retrieval of needed data,'” cited Hjort. “These standards address both the paper and electronic environments.”

Alternate Universes

While Stober sees record consistency with 75 percent of his clients, “For the other 25 percent, the order is similar with only slight variation,” he volunteered. “We find this consistent structure across all hospitals and even across multiple years of records.”

In the paper tradition, there’s an established chart order aided by tab dividers, said Hjort, though order preferences vary among organizations and even specialty units. Furthermore, “this practice has evolved as a collaborative practice between patient care units and HIM,” she added.

“Before universal chart order, we had a disconnect between the caregiver experience on the unit at the point of care and the post-discharge uses of the chart,” noted Hjort. As caregivers typically need the most recent documentation on top, after discharge, “the order was traditionally reversed—changing from reverse chronological order to chronological order—so it reads more like a book,” she explained.

Although reassembling has been a “past practice,” she added that HIM has been “moving toward a best practice, proving we can have cost savings and efficiencies if we use a universal chart order to fit everyone’s needs.”

For example, Hjort offered, psychiatric, pediatric and OB records have distinct nuances. “These specialties involve different forms and types of documentation, so the chart order varies to accommodate these unique documents.”

The Great Divide, Numbers, etc.

Along with the evolution of practices comes the sophistication of tools. “In the paper environment, we see a trend moving toward color-coded, tabbed dividers,” said Stober. “We expect this to continue because tabbed dividers help reduce the labor involved in retrieving information,” he noted. “In addition, tabbed dividers give the physician the capability to review comparative data more easily.”

Another method is the use of form numbers to cross reference order. A visit to The University of Texas Medical Branch HIM Web site at shows the extensive forms and corresponding numbers that can make up a medical record.

At UTMB, when new forms come in, they’re sent to a committee for a number assignment, according to Tracie Boyd. “We don’t chronologically number our forms 1,2,3,4,5, in the record,” she clarified, “but we do use a reference guide for the medical records staff.” Called “flicking,” staff can ensure the record is in order by cross-referencing with form numbers. “They’ll say, for example, form 5867 goes next, form 782 goes next, etc.” And to maintain order, “the guide gets evaluated all the time as forms get added.” Boyd explained.

Periodic review is important, according to Hjort. If a department doesn’t keep up on these additions, “forms in a chart may vary because as new forms are added, old ones may become obsolete,” she cautioned.

Order in the E-world

And yet, the electronic world may render such manual practices as primitive at best, given the search functions, drop down menus and click-and-retrieve capabilities available.

But the concept of chart order remains. For example, order is still maintained in archived charts that feature electronic search capabilities. “Once the records have been scanned, the chart order is archived, and through indexing it can be resorted if desired,” explained Stober. “We can go back and show the exact order of a document that was captured as it sat in the record.” Not surprisingly, however, his office does not get a lot of requests to do so. But if need be, the images are sequentially numbered on the discs EDCO—The Document People returns to its client after scanning, Stober noted.

What Stober does see is users’ desire to view the electronic documents in a paper format. “EDCO has developed the infrastructure to provide an electronic solution to display color-coded tabs in the electronic document management system. By indexing the tabs, the documents will align themselves under the appropriate tab such as Face Sheet, Lab, Radiology, etc.” He’s seen variations of this in other software. “It’s just the wave of document management software to duplicate what’s already been done with the hard copy so it looks like tabs on the screen.”

This is true even in facilities utilizing more sophisticated record systems. For example, “At the Philadelphia VA Medical Center, we are very advanced in the electronic medical record,” explained Raymond S. Pinder, MS, RHIA, chief of health information management services. “This [or- dered chart] content is extremely important, as you give ‘Note Titles’ to sections of the electronic record.”

Given the search features, drop down menus and indexing functions, the divider tabs of yesterday’s paper record can be seen as comforting images coddling a paper generation into the e-universe.

But we’re not quite there yet. “Many organizations are in a hybrid state,” considered Hjort. “In the paper record, you might find a reference to a current record section maintained electronically, and in the electronic record you may find a reference to a paper record.”

Regardless of the medium, concluded Hjort, order has a place. “We will always have the need for a core established order because, on occasion, the electronic record may need to be printed out in its entirety. When we do this, we’ll need a systematic guide.”

Linda Gross is an associate editor at ADVANCE.

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