HEALTH INFORMATION MANAGEMENT SERVICES

Transcription

1 HEALTH INFORMATION MANAGEMENT SERVICES CONTACTS: Rita Bowen, MA, RHIA, CHPS, Enterprise Director of HIM Services Alicia Blevins, RHIA, CHP, HIM Record Completion/HPF Manager Pat McDougal, RHIT, HIM Coding Services Manager Donna Davis, HIM Statistical Coordinator Yolanda Goode, Transcription Supervisor It is the desire of HIM to assist in any way to assure completion of the patient s medical record in a timely manner. Maintaining and completing accurate medical records is an important aspect of patient care and is a vital part of the resident s responsibilities as a physician, both for the UTCOM and EHS. The rules and regulations for medical record completion have been established by the Medical Staff of the Chattanooga and Hamilton County Hospital Authority in accordance with standards outlined by the Joint Commission and the regulations of the Centers for Medicare and Medicaid Services (CMS). To maintain record completion compliance, these rules and regulations must be followed. LOCATIONS: The HIM Services department is located on East Wing 1 and East wing Basement. Records can now be completed on-line via the Physician s Portal. For technical help connecting to the Physician s Portal contact For other questions regarding record completion, please contact Extension Record Completion 3630 Record Transcription 3991 Medical Record Archives 4186 Release of Information 4185 Coding Services 4175 Enterprise HIM Director 6734 HOURS OF OPERATION The department is open Monday through Friday, 8:00 a.m. to 5:00 p.m. Limited staff is available on 2 nd shift, weekends, and holidays. RESEARCH SERVICE If you should wish assistance with a research project, personnel in HIM will be happy to assist in record retrieval and data display. Due to a tremendous number of required audits, your request must be submitted in writing, according to policy ( ) as far in advance as possible. There is a five-day wait for record retrieval. The hard copy records must be reviewed in the HIM Department, and these records will be re-filed after two weeks. Patient records with a discharge date of September 18, 2006 or after are available on-line via the Physician s Portal and Horizon Patient Folder (HPF).

2 DELINQUENT RECORD POLICY During hospitalization and following discharge, records are reviewed to determine if signatures, reports, etc., are lacking. If the record is incomplete, physicians will be notified of records for completion via the Physician s Portal. Please utilize the Horizon Patient Folder (HPF) Quick Reference Guide as to the process for the following medical record deficiencies: signature, dictation, and missing text. The Chief of the Medical Staff or service may send a certified letter alerting the physician of pending suspension of privileges should records not be completed timely. A record is considered incomplete up to 30 days after a patient s discharge. After 30 days, a record is considered delinquent. Residents should strive to keep their patient records up to date and should not have delinquent records. Failure to comply with this requirement could result in suspension or termination from the program. Medical records deficiencies or delinquencies may be the basis for the Hospital s receiving less than the maximum accreditation status and can cause it to lose reimbursement from Medicare. RECORD COMPLETION 1. A complete history and physical must be dictated or included in the patient chart within 24 hours of admission. NOTE: H&P must be present prior to surgery. An H&P can be recorded 30 days prior to the scheduled admission, but must have a written update upon the patient s admission. H&Ps over 30 days can not be used. 2. Operative reports must be dictated at the time of surgery. Residents must include the attending physician responsible for co-signing the Operative Note and Discharge Summary when dictating. An immediate post-operative note must be written in the patient s medical record. 3. You must document in the progress note when a report has been dictated. The job confirmation number, provided by the dictation system, should be recorded in the progress note. 4. All dictated reports must be dated. 5. Each progress note must be timed, dated, and signed. 6. Each physician s order must be timed, dated, and signed. DICTATION INSTRUCTIONS Any telephone inside and outside the hospital can be used as a dictating telephone. Physicians are asked to call outside the hospital and extension 3901 within the hospital to reach the dictation system. After dialing the number, the dictator will follow the prompts to complete his/her dictation. 1. The first prompt you will hear will be a voice asking for your 6-digit physician ID number: The Medical Affairs department issues the 6-digit physician numbers. It is very important that the physician take care to key his/her complete 6-digit physician ID number at the beginning of his/her dictation when prompted to do so. This number identifies the physician to the system and to the transcriptionist. If a digit is off by one, the dictator is identified as an Unknown User and the

3 systems database will not allow an associate to look up the physician s dictation for future use (i.e. a request is received for an additional copy of his/her dictation, transfer discharge summaries will be hard to identify in the system without the appropriate physician ID number, etc.). 2. Next the dictator will be asked to enter a 2-digit work type. Work types segregate the dictation by specified types of reports. It is equally important that the dictator be careful to key in the right work type. Priority transcription is dependent upon the correct work type being used. STAT Pre-Op H&Ps are easily identified by the work type 19. STAT Discharge Summaries for transfer are identified by the work type 01. The following work types apply at this time: 01 TRANSFER SUMMARY 11 HISTORY AND PHYSICAL 12 OPERATIVE REPORT 13 CONSULTATION 14 DISCHARGE SUMMARY 15 CARDIAC CATH REPORT 16 PROCEDURE NOTE 18 HYPERBARIC WOUND CARE NOTE 19 PRE-SURGERY, PRE-ADMIT HISTORY & PHYSICAL 22 OPERATIVE REPORT ADDENDUM 24 DISCHARGE SUMMARY ADDENDUM 28 HISTORY AND PHYSICAL ADDENDUM 30 SLEEP CONSULT 31 SLEEP STUDIES 41 WEP H&P 42 WEP OPERATIVE REPORT 43 WEP CONSULT 44 WEP DISCHARGE SUMMARY 59 PEDIATRIC EEG REPORT 60 ADULT EEG REPORT 61 PULMONARY FUNCTION TEST 64 INTERNAL MEDICINE CLINIC NOTE 65 CARDIOLOGY CLINIC NOTE 67 DERMATOLOGY CLINIC NOTE 68 NEUROLOGY CLINIC NOTE 69 ENDOCRINOLOGY CLINIC NOTE 70 GASTROENTEROLOGY CLINIC NOTE 71 PULMONARY CLINIC NOTE 72 INFECTIOUS DISEASE CLINIC NOTE 73 NEPHROLOGY CLINIC NOTE 74 PSYCHIATRY CLINIC NOTE 75 ALLERGY CLINIC NOTE 83 SPINE CLINIC NOTE 84 PLASTIC CLINIC NOTE 85 HAND CLINIC NOTE 88 CHILDRENS CLINIC NOTE Other work types will be assigned as needed for future dictation expansion projects.

4 3. The next prompt will ask the dictator for the patient s 8-digit encounter number. The patient s medical record number may be dictated at the beginning of the document after providing the patient s name. The Transcription Division, when requested to retrieve a report, will try to retrieve based upon the patient s medical record number and/or encounter number. Of most significance is that the correct patient encounter number is used for transmitting transcribed reports up to LCR in the hospital s SMS INVISION computer system and the patient s legal health record (HPF). If the dictator is not able to provide the encounter number, please enter all 9 s. If an error is made in keying in the patient s encounter number, just correct the number at the beginning of your dictation. The transcriptionist will correct it in the report. At the beginning of your dictation, please be very careful to state your name, patient s name, and include the type of report you are dictating (i.e. H&P, Procedure Note, Medicine Clinic, etc.). Next to the patient s account number and patient name (please spell if name is unusual), the Date of Service is essential to filing the report in the correct episode of care within the patient s encounter. It is beneficial to dictate the patient s specific encounter number. Thank you for being conscientious in providing this information. Please include the attending physician s first and last name for whom the report is being dictated. The attending physician is required for OP Notes and Discharge Summaries dictated by Resident physicians. This will allow the report to be properly authenticated. At the end of the dictation session, please include all persons/groups/physicians who should receive a copy of the report as a carbon copy (cc). All residents are asked to cc all attending physicians/surgeons on Discharge Summaries, Operative Reports, and Procedure Notes. 4. After completing your dictation, you will want to press key number 6 to receive a job confirmation number and be disconnected from the system. For future reference, documenting the job confirmation number on either the progress notes or orders in the patient s medical record is recommended. If you should want to continue dictating several reports at one setting, you want to press key number 5 to receive a job confirmation number for the previous report and return to step 2 (to enter the 2-digit work type) and the patient s encounter number. When the last dictation has been completed, you will want to press 6 to get the last job confirmation number and be disconnected from the system. NOTE: If the dictator does not use number 6 to disconnect, he/she will have o wait approximately 5 minutes before dictating his/her next report. It takes this long for the system to disconnect the dictator from the system when number 6 is not used to disconnect.

5 5. KEYPAD Operation is as follows: Press 2 Press 3 Press 4 Press 5 Press 6 Press 7 Press 8 Press 9 Record dictation (use only after pause key has been pressed) Short rewind Pause End one report and begin dictating another report. This will give you a job confirmation number after your first dictation. Please press 5 after each succeeding dictation done at one setting in order to receive a job confirmation number for each report dictated. Following the last one, disconnect. To disconnect from the system and receive a job confirmation Number. Short Fast Forward (FF) Rewind to the beginning of the report Go to the end of the report and continue dictating 6. For assistance with your dictation, please call NOTE: Each physician is requested to dictate his or her reports as soon after the episode of care is completed in order that the patient s medical record can be compiled, scanned, and available in the Horizon Patient Folder (HPF) on line for patient care, analyzed, and completed in a timely manner. Each dictator is encouraged not to eat or drink while dictating as this significantly impacts what the transciptionist hears or is not able to hear. Speaking clearly and spelling uncommon drugs, procedures, labs, or words is most helpful to the completion of your dictation. Fast dictation is probably expedient for the dictator but sometimes creates blanks in the final typed report because the transcriptionist may not be able to distinguish what is being said by the fast dictator. The Health Information Management Department wishes to express appreciation to the Resident Physicians for their timely completion of their medical records. Revised 06/2008