Technically Speaking: Sharing Resident Notes

Medical records belong to patients… or, in pediatrics, parents. At any time, a parent (or guardian) can walk into Health Information Management (HIM) and request a copy. But that’s a pretty big hurdle, so the government has been working to make accessing records easier for patients and families. In 2020, the ONC* Cures Act Final Rule (an information-blocking provision) went into effect. This stipulates, among other things, that health care organizations cannot block electronic access to most parts of a patient’s medical record; they must be shared freely. This includes (but is not limited to) clinical notes, lab and imaging results and medication and allergy lists.  You can read all about it here, but be prepared to spend several days digesting it. Fine. No big deal. We’ve actually been doing this for years.

But what about resident notes? Lots of us use those as a framework for our own notes.  Addend, make changes and sign. What happens to those? Well, up until now, the attendings had to click a button at the top of the note to share it. Otherwise it didn’t go anywhere. The reason behind this is that we didn’t want families to be confused by reading a resident note before an attending had a chance to review it and make corrections. Any inconsistencies could undermine trust in the team and/or hospital. So, because the note was created by a resident, it wasn’t shared by default. In cases when the attending forgot to click Share, we were out of compliance. Houston, we have a problem.

Fortunately, Epic came through with a fix. We are now able to separate sharing from releasing when it comes to notes. Sharing now simply means that a note is eligible to be released electronically. It’s not until it’s released that it actually gets pushed to patients and families.  And what magically releases these notes now? Voila—an attending signature! So going forward, all resident notes will be shared… it’s just that they won’t get released until they’re signed by a staff physician.

Parallel to all this, the Centers for Medicare and Medicaid Services (CMS) relaxed their restrictions on attendings utilizing student documentation for billing purposes. This led to student notes being addended and signed. Fortunately, the above also applies to student notes; they’re only released when signed.

Compliance achieved? Yep. Extra work required? Nope. Actually, this new behind-the-scenes workflow requires less work for us! That’s a win in my book!

If you have questions or concerns about this new process, please reach out! Thanks for all you do to keep our patients safe and our organization in compliance!

* Office of the National Coordinator for Health Information Technology

Stephen Dolter, M.D., CMIO

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