/policies/,/policies/administrative/,/policies/administrative/uw-health-administrative/,/policies/administrative/uw-health-administrative/health-information-management/,

/policies/administrative/uw-health-administrative/health-information-management/638.policy

201609245

page

100

UWHC,UWMF,

Policies,Administrative,UW Health Administrative,Health Information Management

Medical Record Forms and Electronic Content Development Design and Major Revision (6.38)

Medical Record Forms and Electronic Content Development Design and Major Revision (6.38) - Policies, Administrative, UW Health Administrative, Health Information Management

6.38

Page 1 of 3


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: Medical Record Forms and Electronic Content Development
Design and Major Revision
Policy Number: 6.38
Effective Date: September 1, 2016
Chapter: Health Information Management
Version: Revision
I. PURPOSE

To provide guidelines for the development, approval, revision and management of medical record content
(paper and electronic) while maintaining compliance with medical record content and formatting
requirements.

II. POLICY ELEMENTS
A. All paper forms used/filed within the UW Health medical record must be developed and approved
by the UW Health – Health Information Management (HIM) Enterprise Content Management
(ECM) team prior to use/filing in the UW Health medical record.
1. The EHR Content Management Committee (ECMC) maintains responsibility to assure
consistent adherence to procedures involving the design, approval, revision, printing and
management of all paper and electronic medical record documentation tools. Minimum
content/formatting requirements are determined based on state and federal regulations as
well as accreditation standards and organizational policies and procedures.
2. As content is built/revised, the strictest regulatory requirement and organizational policy
must be applied to ensure compliance across the organization.
B. All electronic tools built at the system level, and used within the UW Health medical record, must
be reviewed and approved by the UW Health HIM ECM team, and as designated (see IV.D.1-3),
by the EHR Content Management Committee.
C. Content/Formatting minimum requirements for electronic documentation and paper forms is
located in the EHR Content Management and Style Guide found on U-Connect at
https://uconnect.wisc.edu/depts/uwhc/him/enterprise-content-management-style-guide/.
1. Forms owners/content builders are responsible for reviewing and complying with Style
Guide requirements when designing draft forms/tools.
a. Minimum standards are to be addressed prior to presenting to the ECMC for
review/approval.
D. New or revised forms/tools may require approval by various committees or departments prior to
implementation (see the EHR Content Management and Style Guide found on U-Connect).
E. Escalation of compliance and regulatory issues will be taken to the Legal Medical Record
Committee for risk assessment and final decision. The UW Health Medical Record Committee is
the final authority/decision making body.

Page 2 of 3

III. DEFINITIONS
A. EHR/EMR: Electronic health record or medical record - all data pertaining to patient care and
treatment to include that defined as part of the legal medical record and any secondary medical
information.
B. EHR Content Management and Style Guide – reference tool used by EMR content builders, end
users, and Health Information Management to ensure consistent/standardized/compliant build of
the organization’s medical record.
C. LMR: Legal medical record - the organization's official record that is released upon request for
the "medical record". Documentation that comprises the LMR may physically exist in separate
and multiple paper-based or electronic-based forms. The LMR excludes medical records that are
not official records of UW Health even though copies have been utilized by UW Health (such as
outside records).
D. Medical Record: All records related to the health of a patient prepared by or under the supervision
of a health care provider, as provided in Wis. Stats. 146.81(4), in the custody of UW Health.
E. PLUE: Patient Link Up Enterprise - is a system tailored to each location that reduces or
eliminates chart preparation time by printing paperwork for each patient as they check in, rather
than having to prep it beforehand. Forms used in the clinic are duplicated in the PLUE system.
Patient demographics can be automatically printed on each form which eliminates handwriting.
F. Smart Tools: General term for documentation tools that assist clinicians in documenting quickly
and completely in Health link. These tools are Smart Forms, Smart Lists, Smart Links, Smart
Phrases and Smart Text.
IV. PROCEDURE
A. A Service Now ticket is to be submitted for all paper forms and electronic content to be used/filed
within the UW Health medical record.
B. HIM Enterprise Content Management team will work with the requester to develop the paper
form including that content requested by the end-user, as well as all required elements per
regulatory and accreditation standards and UW Health policies.
C. The EHR Content Management and Style Guide located on U-Connect.
D. Electronic content approval requirements:
1. HIM/Content Management Review
a. All system level build that displays within the releasable medical record
(Printable Reports)
b. Letters
2. EHR Content Management Committee Review
a. Associated reports created from New Encounter Types (approved by ACLG)
b. New Note Types
c. New/Revised Chart Review Print Groups
d. Column and Tab changes for Chart Review
i. Filters
e. AVS (all)
f. Any tool used for communication within Health Link
g. Unresolved content issues identified by HIM and/or Health Link Analyst
3. No EHR Content Management Committee Review – Follow Style Guide
a. Patient Summary Reports
b. Snapshot Reports
c. InBasket Reports
d. Reporting Workbench reports

Page 3 of 3

e. Multiple Provider Schedule reports
f. Synopsis
g. Review Flowsheets

VI. COORDINATION

Senior Management Sponsor: CIO
Author: Assistant Director, Health Information Management; Business Systems Supervisor, Information
Systems

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

SIGNED BY

Elizabeth Bolt
UW Health Chief Administrative Officer


Revision Detail

Previous revision: 072014
Next revision: 092019