Journal Q&A (1/03)

Q: What is a "shadow record?"

A: A shadow record is a duplicate record kept for the convenience of a department or healthcare provider. For instance, many emergency departments keep copies of an ER record for a few days or weeks in case of a readmission of a patient.

While shadow records have been around a long time, they are in the spotlight now because covered entities must determine what records are included in their designated record set, which must be available for patient review. If a shadow record is used to make determinations about a patient’s care, then it may be necessary to identify it as part of the designated record set.

A key element is whether or not the shadow record has any other information not recorded in the original record. If information such as phone calls to check on the patient or notes by the clinician is not transferred to the original record, the shadow record should be included in the designated record set. Organizations should identify where shadow records are kept and the reasons for their use and then develop policies and procedures that explain their exclusion or inclusion in the designated record set.


Source: Journal of AHIMA 74, no.1 (2003)