When a Patient is Transferred With Incomplete Records

January 5th, 2016 | Published Under HIE Participants by Jennifer Mensch

Dr. Jeanine Compesi, physician at Kaiser Permanente, practices hospital medicine always outside the “walls” of Kaiser Permanente, as the health plan does not have its own hospital. Patients are often transferred from another care setting to one in which the Kaiser Permanente physician will be taking care of them, so sometimes getting accurate information on the patient can be tricky.

One evening, Dr. Compesi was working the 4:00 pm to midnight shift, so it was outside of normal work hours for the hospital’s medical records department. “I was admitting a patient who was being sent in from an outside freestanding ED. Many times, our patients land at these facilities and if they need to be admitted, they’re transferred to a facility where we can take care of them,” says Dr. Compesi. “For this patient, the clinical information that was sent with the patient was incomplete."

Usually when this happens, Dr. Compesi or her staff will engage in an existing process to have the records sent via fax, which involves several steps and may even take several hours. “Sometimes the records are given to transferring ambulance folks and they get misplaced or sometimes it’s so busy that they forget to send it,” she says.

“Because I participate in CORHIO as a provider, I was able to link to their PatientCare 360® portal from the hospital. For this patient, the entire encounter was all there including the emergency room visit, notes from the ED physician, all of the labs, and the x-ray report. It was incredibly helpful,” says Compesi. “In fact, the patient did have a CT scan of their chest that I was unaware of and that was very useful information for me.”

“This information was in the portal within a couple of hours of that visit to the freestanding ED, so it enabled me to admit the patient, document the labs and the care was provided, make an assessment and then determine a plan of care,” says Compesi. “It was also very helpful for my colleague who picked up the patient the next morning and used my documentation to care for the patient. CORHIO was really helpful for me in treating this patient and minimizing duplication of services.”