Universal chart order aids HIM professionals

Hospitals should dictate their record sequence

Organizing patient charts once was a time-consuming and complicated process. Patient care units generally placed the charts in reverse chronological order. Physician orders and current test results were often in front; dictated reports tended to stay more in the back. Some reports might be color-coded; users memorized these color codes so they knew where to quickly find the information in the chart. It was common for each patient care area to establish its own chart arrangement.

After discharge, the user focus changed with less emphasis on detail, more emphasis on summary information. The chart was then rearranged into chronological order by section when it arrived in the health information management (HIM) area. Some of the dictated reports that would be the most in demand from release of information requesters would now be positioned in the front of the chart for easier dismantling, copying, or for a reviewer who might just want summary information.

"User convenience dictated the order in each hospital area," says Beth Hjort, RHIA, HIM practice manager for the American Health Informa-tion Association (AHIMA) in Chicago.

Then universal chart order was introduced to HIM personnel through benchmarking as a best practice — a policy or procedure that enhances the quality of care, increases efficiency, and lowers costs. (For information on how to enter AHIMA’s Best Practices Awards Program, see story, at right.) Hjort has used universal chart order at hospitals where she was employed. "We saw the value and so did the other hospitals in our comparative group."

Universal chart order saves staff hours in the HIM area, eliminating the need to completely rearrange the chart at discharge, Hjort says. "[The transition] was an excellent time to take a look at the arrangement of the chart, its logical sequence, and the most convenient arrangement. We let the change be directed through the cumulative opinion of the many record users in the hospital. We accomplished that through the Medical Record Committee."

With universal chart order, hospital personnel rely on the use of chart order guides. "We had a set of 10 or 12 different tabs," she dds. Chart holders have top clips or three-ring binder arrangements, and tabs that identify a chart section project from the bottom or the side. "[The tabs] allow someone to quickly glean and find what they need. That was different from the old process where there were no tabs," Hjort says.

Creating a user-friendly system

The tabs identify the separate chart sections and eliminate the need for the record forms to be color-coded. The universal chart order also allows the chart to stay in the same basic order once it comes to HIM; anyone reviewing the chart, familiar or not with the system, can use the tabs to find a particular section.

With chart guides, facilities can custom-design a convenient arrangement since the guides create the user-friendly feature, and order is no longer important, Hjort says.

After discharge, one approach is to leave the guides in the records, even the empty ones. "Our plan was to take them out at microfilming as a complete set so they could be recycled. We wanted to be able to use them later without a lot of rebuilding of the tab set." If hospitals cluster patients with similar problems in patient care units, special chart guides can be part of the tab set for that unit; likewise, other units may use the specialty tab only occasionally and can add it as needed.

The purchase of the customized tab sets is a significant expense upfront, Hjort says. However, that expense is generally offset over time by savings realized in decreased staff hours, the elimination of colored forms, and the ability to recycle tab sets.

Hjort says she was pleased with the change offered by the universal chart order. "It was much more user-friendly for new caregivers or those moving between patient care units. Plus, it reduced HIM staff hours and confusion that can come from training staff [in the old system]. I could see an added benefit to applying the universal chart order concept in health systems where physician providers might be moving between hospital entities."