Deficiencies on the Patient Record

The Patient Record contains the episodes and all their documents for a given visit, as well as the other information for the patient such as medication history, billing packages, client information, etc.

When an episode is Deficient - that is, there are medical record categories required on the episode that have not been added or completed - you can find it by filtering directly on the patient record.

How do I use the filter to find deficient episodes?

On the Patient Record, open up the Filters panel (on the left hand side) and look for All Deficient Episodes.

All episodes and PAs that have incomplete information will appear.  Your focus should be on episodes that are Open or have been Discharged, since PAs will not be considered deficient by the Medical Records Management screen until the patient has been formally discharged. 

Expand the episode to view the categories inside it. 

This episode has two categories that are deficient:  The Surgery category Requires Verification, and the Consult category is Required but has no document present at all.

How do I see all my Deficient Record Groups at once?

Filtering by the episodes as described above will display all episodes and PAs in a collapsed state.  

If you want to see the deficient categories within each episode, you can use the Deficient Record Groups filter to search for them and display them in an open state immediately.

It is not only document and request Medical Record Categories that can be considered deficient.  For example, if an episode type of Outpatient was set up to require that a TPR is added to the episode for it to be complete, then the TPR section will appear with the required status.  Same with SOAPs or a Diagnosis if it was set to required and not added.  

If your patient was given a controlled substance during an inpatient visit that required a MAR, then a MAR may also appear as deficient until the records are complete by a user with the Edit MAR privilege. 

Once the MAR is completed, the deficiency flag will be lifted off the record.