The 6 Key Elements We Document in Every High-Stakes Chart Merge.

In the high-stakes environment of a hospital Emergency Department (ED), patient care always comes first. When an unidentified trauma patient arrives, clinical teams spring into action, often creating a temporary chart to ensure treatment isn’t delayed by administrative processes. This is a critical and standard practice.

However, from a Health Information Management (HIM) perspective, this scenario creates a significant data integrity challenge: the potential for a duplicate medical record. When the patient’s identity is later confirmed, HIM specialists are called upon to cleanly merge the records, ensuring a seamless continuum of care and protecting the integrity of the patient's lifelong health story.

Let’s walk through a real-world scenario that our department recently handled.

The Scenario

Our HIM Data Integrity team received a call from the ED Social Worker. An unidentified trauma patient, initially registered under the temporary name "Trauma John Doe," had been undergoing treatment for several hours. The social work team successfully located family members, who provided the patient’s verified legal name, date of birth, and Social Security Number.

A quick search in our Master Patient Index (MPI) revealed that the patient, Mr. Thomas Elison (DOB: 05/22/1965), indeed had an existing medical record number (MRN) from a visit two years prior. The clinical team was preparing to transfer him to a long-term care facility and needed the temporary chart merged into his pre-existing permanent chart to ensure all documentation, new and old, was in one place.

The Critical Question: Timing the Merge

Before any action was taken, a crucial question was asked, as per our department’s protocol: “Is the patient still undergoing active treatment, or are they being discharged?”

Merging records during active treatment can interrupt real-time processes like medication administration records (MARs) or pending lab orders, which are tied to the original MRN. The Social Worker confirmed the patient was being prepared for transfer out of the ED—the perfect time to execute the merge without disrupting clinical care.

The Case Note

Every action we take is meticulously documented. Here is the case note created for this ticket.

Case Note: Merge of Temporary and Permanent Patient Records

Date/Time of Note: October 26, 2023 15:45

Note Author: A. Johnson, Data Integrity Specialist

Ticket/Reference #: HIM-787-DI

Subject: Merge of MRN 8872023 (Temporary) into MRN 330885 (Permanent) for Continuum of Care

1. REQUEST RECEIVED:

• Date/Time of Request: October 26, 2023 15:20

• Request Received From: Maria Garcia, Social Worker

• Requestor's Department/Unit:Emergency Department

• Method of Request: Phone Call

2. PATIENT INFORMATION:

• Temporary Record: MRN 8872023, "Trauma John Doe"

• Permanent Record: MRN 330885, Thomas Elison (DOB: 05/22/1965, SSN: xxx-xx-xxxx)

• Verification Method: Identity verified by family and matched to existing MPI record using SSN, Name, and DOB.

3. REASON FOR MERGE & RISK ASSESSMENT:

• Reason for Request: To consolidate all clinical documentation from the current encounter into the patient's permanent legal record for an accurate patient history and safe transfer to a long-term care facility.

• Risk Assessment: Confirmed with requestor that patient is no longer undergoing active treatment in the ED and is being prepared for transfer. No outstanding orders were present on the temporary record that would be disrupted by a merge.

4. ACTIONS TAKEN:

• 15:30: Initiated merge procedure in Epic EHR. Designated MRN 8872023 (Temporary) as the "Survivor" and MRN 330885 (Permanent) as the "Master" record.

• 15:32: Verified all encounter data, including clinical notes, lab results, and radiology reports, successfully transferred to the master record (MRN 330885).

• 15:35: Retired the temporary MRN (8872023) to prevent future use.

• 15:40: Notified the requesting Social Worker (Maria Garcia) via secure chat that the merge was completed successfully and provided the single, correct MRN (330885) for discharge and transfer paperwork.

5. RESOLUTION:

Request completed successfully. All data from the encounter is now located under the correct patient identity, MRN 330885, ensuring a complete and accurate medical record.

Step-by-Step Guide to Resolving This Issue

For HIM professionals, following a disciplined process is key to preventing errors. Here is our step-by-step guide for resolving a duplicate record merge in a live clinical environment.

Step 1: Intake and Validation

• Receive the Request: Document who is calling, from where, and why.

• Validate the Information: Do not take the caller’s word for it. Independently verify the patient’s identity in the MPI using at least two unique identifiers (e.g., SSN, DOB, previous address). Confirm the two MRNs involved.

Step 2: Clinical Coordination and Risk Assessment

• Ask The Key Question: “Is the patient still undergoing active treatment or are they being discharged/transferred?”

• Get Explicit Confirmation: Do not proceed without a clear "all clear" from the clinical team. Merging during active care can cause serious safety issues. If the patient is active, place a note on both accounts and schedule the merge for after discharge.

Step 3: Pre-Merge Preparation

• Gather Your Tools: Have both patient records open. Identify which is the temporary record (to be merged away) and which is the permanent, historically accurate record (the master).

• Notify (if required): Some protocols require a quick heads-up to the Health Unit Coordinator (HUC) or charge nurse on the unit as a final check.

Step 4: Execute the Merge

• Follow EHR-Specific Procedures: In Epic, this is done in the Master Patient Index (MPI) tool. In Cerner, it’s done through the Person Merge utility. Carefully select the master record.

• Double-Check Your Selection: This is the most critical step. Selecting the wrong master record is a serious error that is difficult to reverse.

• Confirm the Action: The system will usually show a preview. Review it meticulously before hitting "Confirm."

Step 5: Post-Merge Verification

• Audit the Result: Open the master record. Verify that the encounter from the temporary record now appears in the patient’s chart. Check that key documents are present.

• Retire the Old MRN: Ensure the temporary MRN is deactivated to prevent future duplication.

Step 6: Communication and Documentation

• Notify the Requestor: Inform the initial caller that the task is complete and provide them with the single, correct MRN to use moving forward.

• Write a Detailed Case Note: Your case note is your legal record of the action. It must be thorough, accurate, and timely, just like the clinical documentation you are safeguarding.

Conclusion

Merging records for a formerly unknown patient is more than an administrative task—it’s a vital patient safety function. By ensuring a complete and accurate health record, we empower clinicians to make informed decisions and provide a seamless continuum of care. A strict, communicative, and documented process is what allows us to support our clinical colleagues while upholding the highest standards of data integrity.