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Patient Chart Creation and Closure (1.09)

Patient Chart Creation and Closure (1.09) - Policies, Administrative, UWHC, Department Specific, UW Organ and Tissue Donation

1.09



POLICY
Established Date: April 2008
Effective Date: January 2018
Title: Patient Chart Creation and Closure Policy Number: 1.09

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 1 of 3
PURPOSE

The purpose of this policy is to describe the process of creating and completing a patient chart, including
referral, organ offer, import organ, and local donor patients with and without recovered organs charts, for
the University of Wisconsin Organ and Tissue Donation (UW OTD) to meet all regulatory requirements and
federal and state laws. It is the policy of the UW OTD to ensure that all patient charts are completed in an
accurate and timely manner and access to re-open a closed chart is defined.

FORMS

SRC Checklist – Thoracic Donor Checklist
SRC Checklist – Abdominal Donor Checklist
Local Donor Chart Completion Tool
SRC Checklist – Imports

POLICY

All Patient Charts
A. A UW OTD patient chart is any patient related record in the electronic donor medical record
including referral, organ offer, import organ, and local donor patients with or without recovered
organs..
B. The official patient record will be the electronic chart in the electronic donor medical record
C. Only one patient chart will be created for each patient.
D. All chart completion activities and required data elements will be present in the chart per all
applicable regulations and current UW OTD workflows.
E. Additional quality assurance and other accuracy reviews will be completed as required and per
current UW OTD workflows.
F. When a patient chart is closed, the record will become read-only and no edits can be made. If
edits are needed, the chart will need to be re-opened per the workflow outlined in this policy.
G. Actions completed with a patient chart including but not limited to creating a chart, data entry,
data changes, closing, and re-opening a chart will be documented in the electronic donor
medical record audit trail.

Referral Charts



POLICY
Established Date: April 2008
Effective Date: January 2018
Title: Patient Chart Creation and Closure Policy Number: 1.09

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 2 of 3
H. The referral chart will be completed by a UW OTD organ procurement coordinator (OPC)
according to UW OTD policy 2.01.
I. The senior OPC or designee will close the referral chart after it has been reviewed and before
the 10th date of the following month.

Organ Offer Charts
J. The organ offer chart will be completed by an OPC according to UW OTD policy 3.03.
K. The organ offer chart will be closed by an OPC after the import donor XML has been
downloaded into the electronic donor medical record and it is confirmed the import chart has
been created or after the organ offer is declined.

Import Charts with Recovered Organs
L. The import chart will be completed by an UW OTD surgical recovery coordinator (SRC) according
to UW OTD policy 3.03.
M. The SRC will complete the SRC Checklist - Import to verify all required elements are present in
the chart.
N. After the checklist has been completed, the UW OTD surgical recovery manager or designee will
complete a quality assurance review per the current workflow and will close the chart before
the end of the current month.

Local Donor Chart with Recovered Organs
O. All referrals for organ donation in which a United Network for Organ Sharing (UNOS) ID number
is generated will have a permanent local donor chart, created by an OPC.
P. All local donor activity, any unusual or untoward events and how they were resolved, and all
necessary data elements will be maintained in the local donor chart per all applicable regulatory
requirements and UW OTD workflows.
Q. A SRC will complete the SRC Checklist – Thoracic Donor and/or the SRC Checklist – Abdominal
Donor to verify that the required SRC related data elements are present in the chart within 10
days after the cross-clamp date.
R. An OPC will complete the Local Donor Chart Completion Tool to verify that the required OPC
related data elements are present in the chart and to review specific elements for accuracy and
completeness within 30 days of crossclamp.
S. The OPC signature and date on the Local Donor Chart Completion Tool is verification that the
chart is complete and accurate.



POLICY
Established Date: April 2008
Effective Date: January 2018
Title: Patient Chart Creation and Closure Policy Number: 1.09

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 3 of 3
T. After the Local Donor Chart Completion Tool is signed and dated, the chart will be closed by an
OPC or automatically closed by the electronic donor medical record within 30 days after the
cross-clamp date.

Import and Local Donor Charts with no Recovered Organs
U. All chart creation and closure activities will be completed per the current UW OTD workflows.

Re-opening a Closed Chart in Donor Link
V. If any data entry is needed after a chart has been closed, the chart will need to be re-opened
and placed in “Chart Completion,” which will convert the chart back into a data-entry format.
W. Acceptable reasons for re-opening a closed chart include but are not limited to:
1. Data entry as the result of a medical record review per UW OTD policy 4.01;
2. Data validation for reporting purposes;
3. Quality assurance reviews;
4. The patient is re-referred to UW OTD.
X. Access to open a closed chart is limited to only designated UW OTD staff including but not
limited to the UW OTD managers, regulatory and quality staff, and data coordinator.
Y. UW OTD staff that do not have access to re-open a closed chart will contact a designated staff
member to approve the request and to re-open the chart.
Z. If designated staff are not available to re-open a closed referral and a patient is re-referred to
UW OTD, UW OTD staff will contact the University of Wisconsin Hospital and Clinics (UWHC)
Help Desk to re-open the closed chart.
AA. The UW OTD staff member that requested a chart be re-opened will re-close the chart
immediately after all appropriate actions have been completed or will contact staff that have
access to close charts to complete this action, with the exception of a closed referral that was
re-opened because the patient was re-referred which will be closed per the appropriate referral
chart process noted in this policy.

REFERENCES

UW OTD Policies 2.01, 3.03, and 4.01