Migrating from Paper to EHRs in Physician Practices. Appendix A: Historical Medical Record/Chart Abstraction Checklist—Primary Care

Migrating from Paper to EHRs in Physician Practices. Appendix A: Historical Medical Record/Chart Abstraction Checklist—Primary Care

This checklist can help physician practices migrate all the appropriate data from an individual patient paper record into the EHR. Each record or data element should be expanded upon with descriptions based on the practice’s definitions, the location of the information in the paper chart, and where this information should be indexed in the EHR. The form should indicate time frames for back entering each element (e.g., last physical and pertinent clinic notes, last chest x-ray, last mammogram).

Patient ID __________________________ Name ________________________________

Data to Be Integrated into the EHR	Paper Chart Location	EHR Location	Date Completed	Initials
Problem List
Surgical History
Medications
Vaccination History
Growth Charts
Medical Device/Implant Information (including manufacturer, date, and serial number)
Legal Documentation (such as a living will, advance directive, power of attorney, or legal documents; if available these documents should be flagged in the EHR so they are easily noted to providers)
Allergies
Sample Baseline Documents for Primary Care Continuity of Care: Notes Mammogram Pap smear Biopsy results Dexa scan CT scan/MRI Electrocardiography (EKG) Chest x-ray Colonoscopy Coumadin flow sheet Lab flow charts Consult letters/referrals
Elements for Data Reporting

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Article citation:
AHIMA. "Migrating from Paper to EHRs in Physician Practices. Appendix A: Historical Medical Record/Chart Abstraction Checklist—Primary Care." Journal of AHIMA 81, no.11 (November–December 2010): expanded online version.