2015 CLINICAL CLERK ORIENTATION

Transcription

1 2015 CLINICAL CLERK ORIENTATION Health Information Management Provincial Operations Dictation/Speech/Transcription (DST) AHS escription University of Calgary UCMG Transcription Services UCMG escription

2 What is the Purpose of the Health Record? To serve as a basis for planning patient care and for continuity in the evaluation of the patient s condition and treatment To furnish documentary evidence of the course of the patient s clinical evaluation, treatment, and change in condition during the hospital stay To document communication between the practitioner responsible for the patient and other health care professionals who contribute to the patient s care To assist in protecting the legal interest of the patient, Alberta Health Services and the practitioner responsible for the patient To provide accurate and comprehensive data for use in continuing education, planning, research and financial purposes 2

3 DST Contact and Hours of Operation MTs transcribe: Monday to Friday 7 AM to 8 PM Saturday to Sunday and statutory holidays 8:00 AM to 4:15 PM DST Hotline: Help with speaker code Help with accessing system STAT/Priority report request or - HIM Support [email protected] 3

4 UCMG Contact and Hours of Operation For Support Contact: Phone: Fax: Hours of Operation: Transcription/Hotline Monday Friday: 7 AM 4:00 PM After Hours/Weekends: [email protected] 4

5 AHS DST and UCMG escription Please note that even though you use the same speaker codes for AHS escription and UCMG escription, the systems are not the same. AHS and UCMG have two separate escription systems and dictation cannot be transferred between the two systems. Failure to correctly access and dictate on the UCMG or AHS DST platforms, as outlined below, will result in you being required to re-dictate your reports into the correct system to clarify: UCMG escription system when you are dictating as a UCMG clinical clerk from a UCMG outpatient clinic, you must dictate into the UCMG escription dictation system as per UCMG escription system dictation instructions. Please direct any UCMG escription system questions to [email protected] AHS DST escription system when you are dictating on behalf of an attending within Calgary zone or Cancer Control you must dictate on the AHS DST system as per DST Resource Link Please direct any AHS DST escription questions to the DST Hotline For dictation to be considered within scope for AHS DST, there must be a valid encounter at an AHS facility for the report to be transcribed under. In-scope dictation for AHS escription includes: Cancer Control Calgary Zone» Urgent Care/ER patients» inpatients reports including inpatient consults, discharge summaries, ORs» operative reports for outpatient/inpatient/day surgery» Preadmission Clinic (PAC)» pediatric patients (including outpatient) IMPORTANT Please check with the attending physician BEFORE dictating from a Calgary zone adult outpatient clinical location on the AHS DST system. Very few adult outpatient clinics are supported by AHS DST. Many of these clinics are supported by UCMG Transcription Services, and others have their own internal transcription resources. Please note that using the incorrect system may result in lost dictation and the need to re-dictate on the correct system so that the reports are distributed correctly to support patient care. 5

6 ACCESS TO THE UCMG ESCRIPTION SYSTEM The UCMG escription system ( ) is for UCMG member physicians outpatient clinic dictations. All adult outpatient work dictated from the UCMG outpatient clinics should be dictated using the UCMG escription System. How do you know which system to use? UCMG escription Is the patient in hospital now? NO use UCMG Is your preceptor a UCMG member? YES use UCMG AHS DST escription Is the patient in hospital now? YES use AHS DST Is your preceptor a UCMG member? NO Please check with your preceptor/clinic manager for instructions on non-inpatient dictation. Before beginning to dictate determine which system you should be using to complete your dictation. If you are in doubt, ask your preceptor. 6

7 DST - Training You will have reviewer access to the reports that you dictate. An 8-minute elearning module is available on the web with resources (see link at the bottom of this slide) on keypad prompts, facility codes, work types, workflow, and esignature features. DST Repository & elearning URL: Quick References (PDF) esignature Overview Desktop Login and Sign Save URL to Favourites 7

8 DST System Access & Keypad Prompts SYSTEM ACCESS dial to access the dictation system enter your speaker code, then press # enter the facility code, then press # enter the work type, then press # enter the medical record number (MRN) then press # press 2 to begin dictating press 0 for your Confirmation ID Press 9 to end your report KEYPAD PROMPTS 1 priority when a report is required on an emergent basis press #1 at any time during the dictation 2 dictate - record/pause/resume after pause 3 incremental rewind and playback 4 rewind to beginning of report 54 incremental fast forward 55 fast forward to end of report 0 play confirmation # or receive confirmation # 9 end report: end dictation, receive confirmation #, and log out of system * clear entry if pressed before the #, this will clear the field of info entered by the user if an error has been made, i.e., clears speaker code, facility id, work type, or MRN End/Start Multiple Dictations 71 new dictation, different facility 78 new dictation, same work type 6 new dictation, same facility 8 new dictation, same patient 8

9 DST Facility Codes Please reference the below link for all updated DST resource information: Calgary Zone 191 Alberta Children s Hospital 198 Canmore General Hospital 172 Child Development Centre 187 Claresholm Centre for Mental Health & Addictions 181 Claresholm General Hospital 197 Didsbury District Health Services 192 Foothills Medical Centre 173 High River Hospital 185 Oilfields General Hospital 193 Peter Lougheed Centre 190 Richmond Road Diagnostic & Treatment Centre 194 Rockyview General Hospital 195 Sheldon M Chumir Health Centre 180 South Calgary Health Centre 175 South Health Campus 186 Southern Alberta Forensic Psychiatry Centre 196 Strathmore District Health Services 183 Vulcan Community Health Centre 182 Willow Creek Continuing Care Cancer Control 205 Barrhead Community Cancer Centre 206 Bonnyville Community Cancer Centre 219 Bow Valley Cancer Centre 207 Camrose Community Cancer Centre 217 Central Alberta Cancer Centre 200 Cross Cancer Institute 208 Drayton Valley Community Cancer Centre 203 Drumheller Cancer Centre 209 Fort McMurray Cancer Centre 218 Grande Prairie Cancer Centre 204 High River Cancer Centre 210 Hinton Community Cancer Centre 201 Holy Cross Cancer Centre 214 Jack Ady Cancer Centre (Lethbridge) 211 Lloydminster Community Cancer Centre 215 Medicine Hat Margery E Yuill Cancer Centre 212 Peace River Community Cancer Centre 202 Stollery Childrens Cancer Centre 213 Tom Baker Cancer Centre Covenant 788 Banff Mineral Springs Hospital 9

10 DST Work Types Please reference the below link for all updated DST resource information: 10

11 DST - Distribution of Reports first and last name of all copy recipients must be clearly stated at the time of dictation or the copy will not be sent as requested. all reports will be transcribed or edited by a medical transcriptionist upon completion of transcription reports are distributed before signature by the attending physician: o reports will be electronically distributed to Netcare and SCM (urban) o health records copy will be printed o authoring providers and courtesy copies will be distributed by fax or mail out, based on current practice edits made on reports at the time of review or esignature will be redistributed 11

12 Most Responsible Diagnosis (MRD) The MRD is required for each discharge summary. The MRD is a single diagnosis or condition that consumed the greatest portion of the length of stay or the greatest use of resources (i.e. OR time, investigate technology, etc). Comorbidities: A condition(s) that coexists at the time of admission or develops following admission: significantly affects the treatment received or requires treatment beyond maintenance of the pre-existing condition or increases the length of stay > 24 hours 12

13 REQUIRED PATIENT INFORMATION FOR DATA COLLECTION Clinical Documentation Guidelines Most Responsible Diagnosis (MRDx): Document SINGLE diagnosis/condition that had greatest impact on length of stay Diabetes Mellitus (DM): Document Type 1 or Type 2 (Avoid terms: NIDDM; IDDM or Borderline) Diabetes Mellitus with Hyperglycemia: Document if DM is out of control Infections: Document Specific Organism, if known SIRS: Specify if Infectious or Non-infectious origin Sepsis: Specify if Localized OR Systemic Drug Resistance Organism: Specify if Resistance vs. Carrier Status Pneumonia: Document Specific Organism and COPD if known Pneumonia Type: Lobar vs. Bronchopneumonia vs. Aspiration Flagged Interventions: Document Chest tube & CVC line insertions; Paracentesis / Thoracentesis, TPN, CPR, if applicable Hgb: Specify Anemia in documentation Symptom Condition: Document to the Diagnosis if known Chronic Renal Failure (CRF): Indicate Stage of CRF (1 to 5 or ESRD) Hypertension (HTN): Document due to or hypertensive if linked to a cardiac or renal condition ALL Cardiovascular diseases: Document Hypertension if known Asthma: Specify childhood asthma if known Dehydration: Document if IV fluids used in treatment of condition Post-Intervention condition: Clearly document the condition as Post-op Palliative Patient: Document if patient Palliative on admission 13

14 COPIES OF DICTATED PATIENT CARE DOCUMENTS TO THIRD PARTY/NON-HEALTHCARE PROVIDERS Dictated reports containing personal health information of patients copied to third party/non healthcare providers, such as schools, daycare centres, lawyers, insurance companies, etc., are not distributed through the dictation systems. As per the Health Information Act, a valid written consent signed by the patient/legal guardian must be obtained prior to such a disclosure. It is the responsibility of the physician/allied health professional to confirm that the parent(s) receiving the information is the legal guardian. Consent to Disclose Health or Personal Information form (#01551) must be completed prior to disclosure Consent form must then be forwarded to Health Information Management for processing when the patient chart is managed by Health Information Management. Clinical areas that manage their own records may process the request once consent has been obtained, however, prior to any disclosure, the record must be reviewed for severing as per section 7(2) of the Act. Dictating physician or allied health professional states that written consent has been obtained and placed on the chart. Consent form must still be directed to Health Information Management, Release of Information where the information will be reviewed and processed. Due to risk of security breach, copies of patient care documentation will not be distributed if clear/complete information for the copy recipient is not given at the time of dictation. Best practice to follow when requesting copies is to state and spell the care provider s complete first and last name, city, and specialty. Dictate full mailing address for out of province care providers. 14

15 UCMG escription - DIAL: Enter your speaker code followed by # All UCMG Member Physicians and Trainees must use their uniquely assigned Speaker Code. Codes may not be shared. Enter the 5-digit Clinic Code followed by # Enter the patient MRN number followed #. No MRN? Use Press 2 to begin Dictation of Report. UCMG escription Press 0 for your Confirmation Number Clinic Codes Dictate clearly state & spell: Your full name. Double click PDF icon Clinic name and Location (site) for complete list of Patient name, date of birth, MRN UCMG Clinic Codes Clinic Date Copy Distribution please state full name and location of all recipients Press 9 to end dictation and receive confirmation number CONFIRMATION NUMBER - the confirmation # is your receipt of dictation. Please record this number for future reference. 15

16 UCMG CLINIC CODES All UCMG EScription reports are in the form of a letter. Clinic Codes are used to design the letterhead. You will be prompted to enter an appropriate code when you dictate. Clinic codes are posted in each facility, but if you are unsure ask your preceptor. A full listing of clinic codes will be ed to you upon request. ACH all codes start with Cardiology Ear, Nose, Throat Neurology Neuromotor FMC all codes start with Addiction Centre Adult Cystic Fibrosis Arrhythmia Gastroenterology There are currently over 50 clinic codes based in 13 different facilities. The above is a sampling only. An up-to-date list and other useful information is available at:

17 USING NETSCRIPT TO REVIEW AND AUTHENTICATE YOUR DOCUMENTS: 1. Go to 2. Enter UCMG as the CUSTOMER LOGIN 3. Enter your User Name (speaker code) and password 4. At the EditScript Online screen click on Clinicians and then on esignature 5. Change your password as requested 6. Click on Clinicians again, and choose esignature. 17

18 Retrieving a Patient Report on Netscript for Review A table of transcribed reports awaiting your approval will be visible By default, the check boxes selecting all reports are marked. Select View/Sign button to open the reports. (Reports with check boxes selected will be brought forward for viewing.) A New Dictation view will result The Clinician can now review the transcribed report and complete various actions and/or activities. Select Save & Sign button to move the report forward into the Distribution process. Once a patient s medical report is Saved & Signed it is considered complete and is automatically sent into the distribution process, including uploads to SCM and Netcare. If the medical report has any errors or omissions it can only be updated or corrected through a formal Cancel process requiring the signing Clinician/Preceptor to contact Transcription Services and once edited will require repeating the Clinician Approval (esignature) process. Editing Tip: Do not use special characters or symbols such as #@*&^ or ~. These characters will prevent your report from uploading to SCM and Netcare. 18

19 Dictation Best Practices Concise wording describing the condition(s) and intervention(s) are essential to patient care documentation. If it is not dictated then it cannot be transcribed on the patient s report; therefore, it did not happen. Dictation Best Practices Tool Kit s/dictationbestpractices/tabid/270/default.aspx 19

20 AT THE BEGINNING OF EACH REPORT THAT YOU DICTATE, PLEASE... Clearly state then spell your first and last name. Clearly state then spell the attending physician's first and last name. Clearly state ALL patient demographics: MRN site state then spell the patient s first and last name date of birth & age gender Clearly state the date you are seeing the patient: date of procedure date of consult date of admission & date of discharge date of delivery Clearly state and spell the first and last names of all copy recipients (i.e., referring or family physicians that you require copies of the report to be distributed to). If you do not clearly identify who you want the copy to be sent to, the care provider will need to contact HIM, Release of Information to request a copy for their chart. 20

21 Computers do not think they cannot reason, and unfortunately the software hears what it hears. They cannot reason out that the drug it just spit out onto the page is the wrong medication or dosage. They cannot think if it did not quite hear the word not so it left it out. The person s medical history is now irrevocably changed and without the slightest bit of guilt because it was done by a machine. Speech recognition requires that you be well organized and unambiguous in your dictation style. Have your speaker code, clinic code, and regional health numbers readily at hand. After dictating your report note the confirmation number on your handwritten notes and give those notes to your preceptor or place them in the clinic chart. Letter writing/dictation, like any other skill in medicine, requires practice as well as constructive criticism. In most cases your preceptor will look over your transcribed letter, make some suggestions and give the letter back to you. 21

22 Before you dial in to dictate... Be organized ensure you have all patient care documentation organized before you access the dictation system. If you do not dictate the information we cannot include it in the patient care documentation. Ensure that you set aside enough time to complete your dictation (i.e., do not rushing through the dictation). Please do not eat, chew gum/candy, etc., while dictating it is very hard for the transcriptionists to understand what you are saying when you are chewing and trying to dictate. TO CANCEL A DICTATION: Please do not just hang up in the middle of a dictation and re-dictate the report. Please ensure that you call the appropriate area to cancel the dictation. TO CANCEL: You called AHS DST escription CALL DST Hotline You called UCMG escription CALL We understand that you are learning how to use the dictation system and may intermittently need to cancel a dictation ensure that you call us immediately when this happens so that we can pull your report out of the system so that it is not at risk of being transcribed. Confirmation ID = RECEIPT FOR DICTATION: Always note the confirmation ID for all of your reports so that you can state the confirmation ID and patient s MRN if you need to call to request a cancelation or to prioritize your dictated report. The dictation system instructions have been put together to help ensure that you can complete your patient care documentation efficiently. Our areas cannot run efficiently and meet expected turnaround times when instructions are not followed. When instructions are not followed this causes a decrease in productivity, impacts the turnaround times for all dictated reports and may result in incomplete/deficient documentation which does impact patient care. NEVER share your speaker code with another user. Your speaker code specifically identifies you as the author of the dictated report. 22

23 Questions? 23