lundi 28 septembre 2015

what exactly are old records?

I need help defining what "old records" are in Medical Decision Making to give credit for review. I have credited for old records only for new patients or consults when the information was clearly from an outside source, and rarely for established visits unless the provider specifically noted that they had requested the records.

The suggestion has arisen that a provider should get credit for review of old records when reviewing prior test results in comparison to a current test report. For example, CBC results from today (1 point) compared to the prior 4 results (1 point for old records), CT scan done today (1 point) compared to the last report (1 point for old records). In our specialty, we are constantly reviewing old tests and comparing them to new ones to assess the patient response to treatment or disease progression.

The actual definition of "old records" seems to be a very grey area. Are old records only ever those from an outside provider prior to the date you first saw the patient? Is it records in your own files that you have to review to accurately assess the patient?

Does anyone have any suggestions, opinions or resources to recommend that can help clear this up?

And on a slight side note: what category do pathology or operative reports fall under when counting data?

Thanks in advance!


what exactly are old records?

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