What is the required documentation in a patient's medical record for transfusion of blood and blood products when an electronic medical record is employed?

A colleague in Florida reports that his facility's general laboratory cumulative report (which is included in a final discharge lab summary at the time of a patient’s discharge) includes a list of all transfused components with unit numbers. This report serves to document transfusions in the event that individual unit tags become separated from a patient’s medical chart. However, his hospital’s medical records department wants to stop printing and filing final discharge lab summaries for patient medical records, since all of the lab results (but not the laboratory generated transfused component lists) are now available in a patient electronic medical record. The transfused component list, which is not currently part of the electronic medical record, resides only in the laboratory information system. The Florida colleague wants to know if there are any regulations or requirements that a list of transfused components be generated by the laboratory and appear in the patient’s medical record to be accessible to treating physicians, or is it sufficient for this information to be kept only in the laboratory information system? What are colleagues doing with regards to documention of transfusion of blood and blood products when an electronic medical record is employed?

The following responses were received.

ADDENDA May 19, 2003

1. A colleague in Pennsylvania is concerned that if a patient's chart lacks evidence of the transfusion of a specific blood product, a reimbursement audit by the Center for Medicare and Medicaid Services (CMS) for any charges associated with that blood product may produce an allegation of fraud and abuse. The Pennsylanian goes on to say that if his concern is supported by a hospital's legal or audit department, such a possibility should supersede any contention of a medical records department to not include in the electronic medical record listings of transfused components. He concludes that in his opinion, "the REAL headache of an electronic medical record is recording patient consent". He wonders if hospitals have a method of capturing informed consents electronically? In his experience, only Sears and Lowe's Home Improvement stores have electronic signature pads, and they break down frequently.

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