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Subject:
From:
Phyllis Adamson <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Sun, 25 Jul 2004 11:08:42 -0700
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Hi Cathy, et al

With the caveat of "I may be wrong, but..."  My understanding of a shadow
record is anything with personal / medical info on it that is kept in
someplace other than in the official hospital, physician's office, or PPLC
patient files.

For example, when I collect BF data off our internal network, I note name
and ID#. It serves as a double check until I am sure I have the numbers
right. The documents with the name and ID# must be destroyed, but all the
basic numbers can be kept. I have been told that keeping my tic sheets in
writing, or on Excel in my computer, constitutes a shadow record because it
can lead someone to any individual medical record. BTW, we do follow
standard security procedures of logging out/off, keeping our passwords
private from each other, locking the door, etc.

I can't 'see' a woman in the hospital post d/c because she is no longer an
inpatient and we can't charge for my time with her. Well, we can't charge
for my time anyway because my wages are part of the standard Capitated Amt
for any woman's birth. I also have no physical place to see her. So when I
get a phone call for help, I must write it down, and I am forced into a
position of "you must/you must not" with the written record of that phone
call. So I do have what I believe to be shadow records.

Just had an "ah-HAH": What about my lists of daily referrals with name,
PID, room/bed, & problem phrase? And the lists the interpreters keep of
calls with Stn, RN/MD, name, PID, purpose, & time spent? All are patient
identifiers that can lead to a medical record, and are kept in a location
other than the patient's medical record. Can any of the lawyers on the list
offer some suggestions on this?

Once in a while I can answer a call to the clinic next door. My report goes
into the baby's medical file in that clinic. No problem there. Once in a
while an MD from that clinic will call with a question about a patient. I
have no clue how, or if, that is documented.

I appreciate the sounding board to sort this stuff out.

Phyllis


> Thanks for your feedback on documenting phone calls.
> You had mentioned that keeping a file of phone consults in the lactation
> office creates a 'shadow' record that HIPAA & JCAHO forbid.
>
> If that is really true it seems to be an odd kind of regulation.
> Shouldn't it be quite expected that any kind of "Medical" office to have
> files of patient/client consult records including phone calls?  I mean the
> whole reason for documenting the phone consult in the first place is to
> keep a record of what was advised not only to "CYA" but to provide a
> record for partners to refer to in the interests of keeping advice
> consistent. So I am not sure why HIPAA and JACHO forbid this.
>
> I guess I need to know what is meant by 'shadow' record. Is there some
> document put out by HIPPA or JHACO that defines this term?
>
> Many thanks
> Cathy Loughman RN IBCLC

--- Phyllis Adamson, IBCLC, RLC
--- Glendale, AZ, USA
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