Edmonton Zone or TO ACCESS THE EDMONTON DICTATION SYSTEM DIAL: Health Information Management Transcription Services

Transcription

1 Edmonton Zone Health Information Management Priority dictations, obtaining a dictation User ID #, or any other inquiries during regular business hours: Grey Nuns: (0700 to 1500 hours) Misericordia: (0800 to 1600 hours) TIPS TO ENSURE ACCURATE SERVICE, ALWAYS: Prepare/organize data before beginning dictation. State and spell your first and last name. State the name of the attending physician. State and spell the patient s first and last names. State the patients date of birth (i.e. 4 June 1963) State the patient s complete Medical Record Number (MRN). State and spell the first and last name for copy recipients (i.e., family/referring physician s etc.). ** The copy will not be sent if there is uncertainty regarding the intended recipient. State ALL dates pertinent to the dictation (operative date, admit & discharge dates, etc). RESIDENTS/CLINICAL CLERKS/FELLOWS/CLINICAL ASSOCIATES/STUDENT INTERNS: Always state the attending physician s first and last name at the beginning of each dictated report. TO ACCESS THE EDMONTON DICTATION SYSTEM DIAL: or Enter your personal dictation identification number followed by #. If prompted for a zone identifier, enter 1 for Capital Health. Enter the numeric patient location identifier followed by # Numeric ID Patient Location description Numeric ID Patient Location description 1 Glenrose 10 Devon 2 Grey Nuns 11 Redwater 3 Leduc 12 Westview 4 Misericordia 14 Morinville 5 Royal Alexandra 15 Health First Strathcona 6 Sturgeon 16 Stollery 7 University of Alberta 17 Alberta Hospital Edmonton 8 Fort Saskatchewan 18 Northeast CHC 9 DKML 19 Villa Caritas Enter the numeric work type identifier followed by # Enter the Patient ID number (MRN) followed by # Enter the Case Number followed by # Intermittent tone PRESS 2 to begin dictating. Work type number Description Work type number KEYPAD FUNCTION NUMBER 2 Start and stop dictation 3 For incremental rewind with automatic playback 4 For fast forward 44 To forward to the last word dictated 5 To complete and disconnect 7 To rewind 77 To rewind to the first word dictated 8 To complete current report and start a new report Description 1 Histories (inpatient) 6 Obstetrical Discharge Summary 2 Consultations (inpatient) 8 EEG/EP Reports 3 Discharge Summaries 10 Outpatient Clinic Reports 4 Operative Reports 12 Letters (outpatients) 5 Procedure Reports 33 Transfer Summary

2 IMPORTANT INFORMATION Please always remember to use a corded land line and speak clearly, slowly and directly into the phone - as if you were speaking to a patient. Ensure you always use the correct work type. The work type that you key into the dictation system = the template format and distribution that the transcription system will use for your documentation. Using the wrong work type may result in your report being routed for transcription incorrectly. There are many doctors with similar names so please ensure that you clearly state and spell the first name, last name and state the specialty for care providers that you need copies to be sent to (i.e., family, attending, etc). Ensure that you always identify yourself and state the first and last name of the attending physician that you are working with at the beginning of each dictated report. If you were cut off and have an incomplete report, dictate the second portion making reference to the Job ID and MRN of the original report and state that you are dictating an addendum or a continuation of the previous report. o Please note that you may not add an addendum to a report that you did not originally dictate. Do not enter any incorrect patient information; this results in delay of the report being transcribed and physician deficiencies will not be updated. Do not use another dictator's dictation number. If you do not have a dictation number, please call at your site (see page 6) to obtain one. Do not dictate more than one patient or more than one report per dictation. Any dictations containing more than one report will only have the first dictation transcribed; the remaining dictations will need to be re-dictated. Please DO NOT access the dictation system while: o in a noisy environment (i.e. background noise, side conversations, operating room scrub station, etc.). o using a cordless or cellular phone or other wireless devices - signal/reception fluctuates and results in inaudible dictation. o using a phone line with static - If you can hear static on the line please do not continue to dictate. The static records louder than your voice, making your dictation inaudible. o eating, chewing gum, eating candy, etc.

3 WORK TYPES BY HOSPITAL LOCATION COVENANT HEALTH SITES: Grey Nuns Community Hospital (patient location 2): 1 Histories (inpatient only) 2 Consultations (inpatient only) 3 Discharge Summaries (for inpatient admissions only) 4 Operative Reports 5 Procedure Reports 6 Obstetrical Discharge Summaries 8 EEG Reports/Evoked Potential Reports 10 Outpatient Consultation 12 Outpatient Letters (to referring physicians only) 33 Transfer Summary (Nurse Practitioner use only) Misericordia Community Hospital (patient location 4): 1 Histories (inpatient only) 2 Consultations (inpatient only) 3 Discharge Summaries (for inpatient admissions only) 4 Operative Reports 5 Procedure Reports 6 Obstetrical Discharge Summaries 8 EEG Reports/Evoked Potential Reports 10 Outpatient Consultation 12 Outpatient Letters (for irsm and Dr. Boychuk only) 33 Transfer Summary (Nurse Practitioner use only) Villa Caritas (patient location 19): 1 Histories 2 Consultations 3 Discharge Summaries

4 Discharge Summary Format A discharge summary should be a brief synopsis of the significant events occurring during a patient s hospitalization. Please include paragraph headings in your dictation. AUTHOR: Identify yourself and your title. House staff and student interns new to the hospital should spell their surnames. PHYSICIAN RESPONSIBLE: If different from the personal doing the dictation. PATIENT NAME: State surname first and spell, follow with the given name and spell. PATIENT IDENTIFICATION NUMBER: This is the patient s Medical Record Number (MRN). This number appears on the Patient Registration Form. COPIES TO BE SENT: Indicate copies for WCB, Cross Cancer Institute and other physicians. Spell the physician s SURNAME, give the FIRST name and address as complete as possible. ADMISSION DATE: This date appears on the Registration Form. DISCHARGE DATE: This date appears on the Registration Form. DATE OF BIRTH: DOB is for patient ID verification and is on the Registration Form CLINICAL HISTORY: Include reason for admission and relevant history of past health. PHYSICAL EXAMINATION: Include mental status examination if appropriate. INVESTIGATIONS: Include all SIGNIFICANT lab, radiology findings normal or abnormal. TREATMENT AND PROGRESS: Include significant events of patient s hospitalization and condition on discharge. INCLUDE OPERATIONS STATING EACH PROCEDURE PERFORMED, DATE OF PROCEDURE AND SURGEON S NAME. DISCHARGE MANAGEMENT PLAN: Include where the patient was discharged (i.e. home, nursing home, etc.), follow-up physician and follow-up investigations. List the medications and dosages the patient was discharged on. Please spell out any uncommon medications. CONSULTANTS: List each consultant, giving surname and initial. DISCHARGE DIAGNOSES: USE THE FOLLOWING FORMAT WITHOUT ABBREVIATIONS OR SYMBOLS. MOST RESPONSIBLE DIAGNOSIS: The one most significant condition responsible for the stay in the hospital. PRIMARY DIAGNOSES: Other important conditions that significantly impact the patient s management or length of stay, i.e. CONTRIBUTES TO THE COST OF THE HOSPITALIZATION. SECONDARY DIAGNOSES: An incidental condition which did not contribute to the length of stay and for which the patient may or may not have received treatment. COMPLICATIONS: A condition arising after a patient s hospitalization which has a significant influence on the patient s management or length of stay. NOTE: This may also be the Most Responsible Diagnosis.

5 Obstetrical Discharge Summary Format An obstetrical discharge summary should be a brief synopsis of the significant events occurring during a patient s hospitalization. Please include paragraph headings in your dictation. AUTHOR: Identify yourself and your title. House staff and student interns new to the hospital should spell their surnames. PHYSICIAN RESPONSIBLE: If different from the person doing the dictation. PATIENT NAME: State surname first and spell, follow with the given name and spell. PATIENT IDENTIFICATION NUMBER This is the patient s Medical Record Number (MRN). This number appears on the Patient Registration Form. COPIES TO BE SENT: Indicate copies for WCB, Cross Cancer Institute and other physicians. Spell the physician s SURNAME, give the FIRST name and address as complete as possible. ADMISSION DATE: This date appears on the Patient Registration Form DISCHARGE DATE: This date appears on the Patient Registration Form. CLINICAL HISTORY: Include reason for admission and relevant history. PHYSICAL EXAMINATION: INTRAPARTUM EVENTS: Include significant labor events. INCLUDE CESAREAN SECTION OR OTHER OPERATIONS STATING EACH PROCEDURE PERFORMED, DATE OF PROCEDURE AND SURGEON S NAME. NEWBORN OUTCOME: Specify normal or if abnormal indicate nature of problem and follow-up DISCHARGE PLAN: Include mention of where the patient was discharged (i.e. home, other facility, etc.), medications, follow-up physician and follow-up investigations. DISCHARGE DIAGNOSES: USE THE FOLLOWING FORMAT WITHOUT ABBREVIATIONS OR SYMBOLS. MOST RESPONSIBLE The one most significant condition responsible for the greatest DIAGNOSIS: PRIMARY DIAGNOSES: SECONDARY DIAGNOSES: COMPLICATIONS: length of stay. Other important conditions which significantly impact the patient s management or length of stay, i.e. CONTRIBUTES TO THE COST OF HOSPITALIZATION. An incidental condition which did not contribute to length of stay and for which the patient may or may not have received treatment. A condition arising after a patient s hospitalization which has a significant influence on the patient s management or length of stay. NOTE: This may also be the Most Responsible Diagnoses.

6 MEDICAL TRANSCRIPTION SERVICES Edmonton Dictation numbers: or (i.e. a physician calls and asks for the number they use to Dictate into) BUSINESS OFFICE HOURS OF OPERATION: COVENANT HEALTH GREY NUNS TRANSCRIPTION SERVICES: Monday to Friday Phone: COVENANT HEALTH MISERICORDIA TRANSCRIPTION SERVICES: Monday to Friday Phone: AFTER HOURS (evenings, weekends and statutory holidays): Questions, inquiries, obtaining Author/Dictator Identification Number for Physicians, Residents and Students: GREY NUNS TRANSCRIPTION SERVICES: Leave a message at MISERICORDIA TRANSCRIPTION SERVICES: For technical assistance (i.e. cannot access dictation system), call the Information Center Help Desk: