MR-005 Content of the Legal Electronic Medical/Mental Health Record Attachment E-History of the Medical Record SHS Medical Record History 1983: Microfilmed paper charts from l983 through 1990 1986: CAPS separated from SHS and started their own medical record. 1987: The hospital and emergency room closed 1989-1991: Medical records with last date of service 1978 to 1983 were microfilmed 1990: Physical therapy documentation was placed in a shadow medical record and retained in the physical therapy department. 1991: Occupational Health Services (OHS) separated from SHS. All medical records with only employee information were forwarded to OHS. Any medical record with both student and employee information was retained at SHS. When OHS wanted ‘employee’ records from the student medical record, the original employee records were sent to OHS and copies were kept in the SHS medical record. 1993: Stopped requiring entrance requirements for new incoming students 1994: Medical Manager practice management system was begun. 1998: Providers starting signing off on original lab reports 1998-2004: Medical records with last date of service of 1982-1992 were destroyed and destroyed information documented in Medical Manager and Point N Clinic. (1998 records destruction 10 years; 2008 record destruction started after 7 years) l999: Providers started signing off on original x-ray reports 2000: Started adding note to all record releases regarding the need for a new authorization for re-disclosure of information. 2002: Antigen records were returned to the Medical Record. Health Education notes were added to the medical record. 2003: HIPAA Privacy began April 3, 2003 Physical therapy charts where returned to the medical record. 2004: HIPAA Security began April 2005 2005: PnC practice management system was implemented August 2005. May 2005 started Digital x-ray 2007: March 2007, order entry was begun in PnC. Providers started to acknowledge lab and x-rays in PnC. RN Triage began electronic documentation August 2007 the EMR was begun and the paper medical record closed. Paper charts pulled initially as a reference then stopped and provider requested when needed. 2008: January 2008: A box of old employee microfilmed records was located and given to Occupational Health Services. Summer 2008: medical records with last date of service of 1992-2000 were destroyed. Documentation of those destroyed records are maintained in a Paper Destruction Log filed in the ROI office. 2009 Stopped antigen at SHS – all antigen issues went to Dr. Brown Old microfilmed records on cassettes were securely destroyed, as we could no longer access them because they were sticking together – decision made at MR Committee to destroy. Remaining Paper records sent to Off Site storage, yearly destruction began. Permanent storage for records containing workers comp documentation - will evaluate at a later date what to do with these records – possibly scan. 2010 March 29 moved to new building 2011 7/1/11 CAPS and SHS merged to one EHR with three divisions. CAPS 4D record cleaned up and available as a reference to CAPS staff 7/1/1

07/11, 02/13