Policies,Administrative,UW Health Administrative,Health Information Management

Procedures for Approval and Elimination of Existing Subcharts and Shadow Charts to the UW Health Primary Medical Record (6.28)

Procedures for Approval and Elimination of Existing Subcharts and Shadow Charts to the UW Health Primary Medical Record (6.28) - 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: Procedures for Approval and Elimination of Existing Subcharts
and Shadow Charts to the UW Health Primary Medical Record
Policy Number: 6.28
Effective Date: August 23, 2017
Chapter: Health Information Management
Version: Revision


To provide procedures for the approval and elimination of existing subcharts and shadow charts.


A. As UW Health (formerly University of Wisconsin Hospital and Clinics Authority and University
of Wisconsin Medical Foundation) have moved to an electronic medical record (EMR), new
subcharts or shadow charts are no longer approved and existing subcharts will be eliminated. As
departments/clinics begin documenting in the electronic medical record, a department
representative will work with the Health Information Management File Room Manager to
coordinate the integration of all documentation into the EMR and the elimination of existing
subcharts and shadow charts.

B. Release of Information from ANY subchart OR shadow chart shall be in accordance with state
statutes and Hospital Administrative policies 4.10, 4.13, 4.30 and 4.38. Departments and units
should attempt to have all releases completed by UW Health, Health Information Management

C. The existing subcharts shall be made available immediately upon request when needed in
conjunction with the primary medical record (i.e., patient care or Release of Information).

D. The following minimal patient information will also be noted in the appropriate section of the
patient’s electronic medical record: problem list, medications, allergies and health maintenance.

E. All original documents that ultimately require inclusion in the UW Health record will conform to
standards for medical record forms and must be approved by Enterprise Content Management.

F. The subchart shall be maintained in the same format as the primary medical record. All
documents shall contain two patient identifiers to include the full patient name and medical
record number. Documents shall be filed in order of document type, in reverse chronological date

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G. All documents that are created/received by health care providers and advanced practice
professionals at UW Health, but will NOT be included in the UW Health medical record, are
subject to State of Wisconsin statutory requirements for the retention and/or disposal of

H. Purging of the subchart / merging with the primary medical record will be coordinated between
the clinical location and the Health Information Management File Room Manager.


A. A "primary record" contains all original medical documentation from a patient's admission and/or
outpatient visits. It is retained by the UW Health, Health Information Management Department,
in the electronic medical record, or at a designated file location and is considered the legal
document of care.

B. A "subchart" is a folder containing original medical documentation that is not kept in the UW
Health primary medical record. A subchart may also contain copies and/or other material that
may be purged. The distinguishing characteristics of a subchart are that it contains ORIGINAL
MATERIAL that would be considered a part of the UW Health medical record. To eliminate
subcharts and shadow charts, departments are strongly encouraged to work with Health
Information Management to include pertinent clinical documentation in the EMR through
electronic submission that is not automatically included in the EMR..

C. A "shadow" chart contains ONLY COPIES of documents in the UW Health primary medical
record. As the UW Health EMR is the primary source of clinical documentation, there should be
no need to maintain copies of any documentation in department files. Departments are strongly
encouraged to confidentially destroy all existing shadow charts.


Record Retention/Disposal Disposition-State Form PRFB1


A. Health Information Management maintained an index of approved subcharts and the dates that
they were eliminated. There will be no new subcharts created.

B. When a patient's subchart is no longer needed for active patient care, the clinic will contact
Health Information Management (HIM) (608-203-4605) to arrange for the combination of
original material from the subchart with the UW Health medical record and/or EMR through the
manner deemed most appropriate by HIM.
1. The subchart shall be reviewed by the originating clinical department, and documents,
verified as original approved medical record documents will be forwarded to Health
Information Management for filing and/or inclusion into the primary medical record. The
subchart shall be taken apart, all original documents clipped together with the patient’s name,
date of birth and MR number clearly identified on the first page.
2. As arranged with HIM, purged information is sent via separate mode of delivery to avoid
mixing subchart documents with current patient care documents.
3. HIM will combine the purged subchart information with the primary medical record and/or
include the documentation in the EMR according to existing policies.
a. The original and necessary information from the subchart that was not included in the
EMR will be placed in long-term storage as part of the primary medical record by Health

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Information Management. Subchart purges should take place generally after 18 months of
inactivity for a given subchart (at six months for expired patients).

C. Each shadow chart shall be confidentially destroyed per WI State Statutes. Retention time can be
determined by the individual department or clinic, but extended storage will not be provided by
the UW Health or its entities. HIM may be contacted for consultative services.

D. Electronic File Cabinet (EFC)
1. Departments may request that clinically significant information contained in paper shadow
charts be considered for inclusion into an Electronic File Cabinet (EFC) housed within
OnBase. The EFC allows the information to be maintained within the document imaging
system, separate and distinct from the hospital’s electronic medical record system.
2. The UW Health Document Imaging (DI) Workgroup will review all requests for EFC
inclusion and will forward approved proposals to the Medical Record Committee (MRC) for
final review and approval. HIM staffing concerns will also be considered prior to approval.
3. A HIM will retain scanning and indexing responsibilities for the EFC when the
documentation is clinical in nature. When appropriate and approved by the DI Workgroup
and MRC, the department will be given security to scan and view specific documentation
directly in the EFC.


Sr. Management Sponsor: VP, Chief Information Officer
Author: Director, Health Information Management
Reviewers: Medical Record Committee

Approval Committee: UW Health Administrative Policy & Procedure Committee


Elizabeth Bolt
UW Health Chief Administrative Officer