Policies,Administrative,UW Health Administrative,Health Information Management

Paper Medical Record Control (6.10)

Paper Medical Record Control (6.10) - Policies, Administrative, UW Health Administrative, Health Information Management


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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Foundation (UWMF).
Policy Title: Paper Medical Record Control
Policy Number: 6.10
Effective Date: March 1, 2017
Chapter: Health Information Management
Version: Revision

To establish and maintain a record control system for all circulating paper medical records and documents
in order to ensure medical record availability for purposes of patient care, timely billing, support for
research and as required by state, federal and regulatory guidelines. Use of the electronic record is
recommended as a first resource for patient information providing immediate access.

A. It is UW Health's goal to provide complete medical record availability (either electronic or paper
form), to all requesters. Factors influencing success are listed within this policy. Accountability of
records lies with the borrower, whether the borrower is faculty, researcher, clinical staff or
clerical staff. Once the primary paper record is issued and leaves Health Information Management
(HIM), it becomes the responsibility of the borrower to maintain its whereabouts, and the
borrower must notify HIM if there is a change from the original issue location.
B. Paper documents received outside of HIM are the responsibility of the receiver and remain so
until the document is transmitted electronically or the paper is received by HIM for inclusion in
the electronic medical record (EMR).
C. Standard procedures for processing paper medical record requests are as follows:
1. All requests are processed the day the request is received in HIM and sent to the
requesting location within 24 hours (Monday – Friday).
2. Old paper medical record documentation will be scanned and indexed into the EMR upon
D. Paper documents will be made available in the EMR according to established priorities.
E. Duplicate records (paper and electronic) will be reviewed by the HIM Identity team and will be
merged as appropriate as soon as possible after the patient is discharged from any active

Each borrower will be responsible for tracking the location of the requested paper medical records on the
appointment schedule or other internal locator system.
A. Requesting Paper Medical Records

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1. Complete the Paper Chart Request form in Health Link (Epic – HIM – Paper Chart
Request. Please complete all fields.
2. Please contact HIM at 608-203-4603 for help or follow up.
B. Moving Medical Records
1. The new location of any medical record not being returned to HIM must be entered into
the Health Link chart tracking system. This may be done by one of the following:
a. Calling HIM at 203-4603 and leaving a message to include patient name, medical
record number, DOB, the borrower's name, room number and phone number as
to where the chart will be moved.
b. Email at medrectransfer@hosp.wisc.edu and include patient name, medical
record number, DOB, the borrower's name, room number and phone number as
to where the chart will be moved.
2. Medical records that contain multiple volumes are to remain rubber-banded together.
3. Paper documents can be sent to HIM via the following methods
a. Paper, through inter-d mail or HIM pick-up.
b. Fax (contact the HIM Manager at 608-203-4596)
c. Decentralized E-scanning (contact the HIM Manager at 608-203-4596)
C. Incomplete Discharges
1. Paper inpatient documentation will be picked up by HIM staff or sent to HIM via
Decentralized E-Scanning and indexed into the patient's electronic record.

Sr. Management Sponsor: SVP, Chief Information Officer
Author: Director, Health Information Management

Approval Committee(s): Medical Record Committee; UW Health Administrative Policy and Procedure


Elizabeth Bolt
UW Health Chief Administrative Officer

Revision Detail:

Previous revision: 032014
Next revision: 032020