By Dr. A. Carbonell
From time to time patients will bring outside medical records to be addressed by you or outside records will be faxed into the clinic. If you are consistent in the way that you document outside medical records it will be easier to refer to them in the future:
Documenting outside medical records:
1. Open an administrative encounter (New Visit, TPA ADMIN, LAK ADMIN etc.)
2. Click new note and select note entitled “Review of outside clinical documents”
3. Dictate a summary of the information that was faxed to you & sign.
-Once you have completed your documentation submit the outside records to ROI (place in the ROI box at your facility so that it may be scanned into the EMR - you will not be notified when it is scanned into the computer that is why it is important for you to document the results and address as needed)
What if I need to order consults or imaging?
My policy is if the records recommend repeat imaging, consultation to a specialist, repeat labs etc. I tag my nurse to call the patient and discuss whether the patient completed this in the private sector or would like to complete through the VA, I am especially careful of this with outside ERs/hospitalizations as they will not arrange follow up for the patient after an ER visit or discharge from a Non-VA Facility. I make this addendum and tag my nurse directly on the “review of outside clinical documents” note that way not only are the outside records documented but my response to the outside records is also clearly documented.