Folder Structure of Clinical Notes

You've probably noticed by now that the folder structure (or hierarchy) of the clinical notes has changed. While it is not likely to be dramatic change to most patient charts, it may cause some head scratching for patients who have been in and out of the hospital and to many different clinical sites. The main gist is that the folders are no longer organized by location. There are now three major folder headings:

• Requests, Authorizations, Contracts & Consents
• Patient Care Documentation
• Non-BH Medical Records Scanned

Patient care documentation will consist of PowerNotes, dictated documents, results, reports, forms, etc and will be organized by specialty. This restructuring will facilitate improvements in organization and importation of clinical documentation whether created in CIS or scanned into the system.

This redesign will not only improve the filing process of documents, particularly those that are used both in the ambulatory and inpatient settings, but will allow for streamlining of the soon-to-be-introduced scanning initiative. While I'll have more to say about this in future posts, this is a major next step in Baystate's journey to the paperless medical record.