Also external records, outside medical records, records from other providers
Every organization’s chart is complete about itself and silent about everyone else. The home health agency’s EHR holds its own visits; the hospital’s holds the admission; the cardiologist’s holds the echo and the consult; the previous primary care practice holds ten years of problem lists. A patient’s history is the union of those, and no one organization has it. “Outside records” is the name for everything in the union that is not in the chart you are looking at.
For an agency at the start of service that is most of the history. The nurse making the initial assessment visit and the interdisciplinary team doing the initial comprehensive assessment work from what the referral source sent and what the patient and family can recall, and the gap between that and the actual history is where the missed diagnosis, the duplicated test and the medication error live.
There are two routes to closing it. The first is to ask: a fax, a phone call, a portal account at each health system, a signed release where someone insists on one. It works one source at a time and takes days per source. The second is to query: a network query under treatment purpose of use that asks every connected organization at once and returns their documents in minutes. The second route produces a pile; organizing the pile into one record, de-duplicated and sourced, is what makes it usable. The discharge summary, the referral packet and the C-CDA entries describe the pieces; chart prep describes the work.