ORIENTATION TO THE HEALTH INFORMATION MANAGEMENT DEPARTMENT

Transcription

1 ORIENTATION TO THE HEALTH INFORMATION MANAGEMENT DEPARTMENT q ORIENTATION q INSERTS 1. DOCUMENTATION GUIDELINES 2. DICTATION OF DISCHARGE SUMMARIES / OPERATIVE REPORTS 3. INSTRUCTIONS FOR DICTATING 4. NORTH SHORE UNIVERSITY HOSPITAL S ACCEPTABLE SYMBOLS AND ABBREVIATIONS 5. SIGNATURE VERIFICATION SHEET

2 ORIENTATION TO THE HEALTH INFORMATION MANAGEMENT DEPARTMENT 1. LOCATION: The HIM Department is lcated in the Twer Building n the first flr. 2. HOURS OF OPERATION: The HIM Department is pen Mnday Friday, 7: am 12:00 midnight. Saturday, Sunday, and Hlidays, 8:00 am 4 pm. T arrange any appintment fr chart cmpletin dial Service is als available in the Dctr s Lunge with cffee and Danish. 3. CHART COMPLETION: a. Nrth Shre University Hspital takes chart cmpletin very seriusly. It is yur respnsibility t cmplete yur charts n a timely basis. The New Yrk State Department f Health as well as the Jint Cmmissin require charts t be cmpleted within 30 days f discharge. Discharge Summaries shuld be cmpleted immediately fllwing a patient s discharge and Operative Reprts have t be dictated immediately fllwing a prcedure. b. Yu will be ntified by the HIM Department via fax if yu have 4 r mre delinquent charts n the Mnday f a given week. If by Thursday f that week yu have nt cmpleted yur charts, a secnd fax will be sent t yu by the HIM Department warning that yur name will be submitted t yur Chairman fr pssible suspensin if yu d nt cmplete yur charts by Friday f that week. It is expected that after yu are ntified that yu will cmplete yur charts by the end f the week. Simply call the HIM Department at extensin 4273 r 4593 and request t have yur charts pulled and they will be ready and waiting fr yu when yu cme in t cmplete them. c. Yur cperatin in cmpleting yur charts as sn as pssible is imperative if the hspital is t remain cmpliant with regulatry agencies such as the Department f Health and the JCAHO. 4. DOCUMENTATION GUIDELINES: (see packet insert #1) In additin t the infrmatin supplied in insert #1, please be aware f the fllwing:

3 a. If it is nt dcumented in the medical recrd, it did nt happen. Please make sure t dcument all pertinent infrmatin. b. Never use whiteut. The accepted technique fr making a crrectin is t place a single line thrugh an errr, initial it and then write the crrectin. c. Never remve any dcumentatin frm a patient s medical recrd. d. Signatures shuld be legible with yur credential nted. e. All entries must be dated, legible and clear. f. Addendums are acceptable but must be dated the date f entry. 5. DICTATION OF OPERATIVE REPORTS: (see insert #2) Please review these guidelines s that yu are familiar with the required cntent and frmat f these reprts prir t dictating. 6. INSTRUCTIONS FOR DICTATING: (see insert #3) Please review this dcument fr directins. In additin, the fllwing infrmatin is ffered: a. Yu will be given a dictating card with yur access number t be used nce yu dial in t dictate. b. Dial t gain access t the dictating system utside the hspital. c. Frm within the hspital yu nly need t dial the extensin d. If yu experience any difficulty in dictating, please hang up and dial and the HIM Department will help yu. 7. NORTH SHORE UNIVERSITY HOSPITAL ACCEPTABLE SYMBOLS AND ABBREVIATIONS: (see insert #4) Please review this dcument fr acceptable symbls and abbreviatins. If it is nt in this listing, it is nt acceptable and shuld nt be written in the chart. 8. REQUESTING A CHART FOR PATIENT CARE: T btain a chart fr patient care, yu may either call extensin 4260 r cme in t the HIM Department with the fllwing infrmatin: i. Patient s Name

4 ii. Medical Recrd Number iii. Lcatin f the Patient (if in-huse) The chart will be lcated and yu will be paged when it is available. 9. ADDITIONAL INFORMATION: a. Medical Recrds are never t be remved frm the hspital building. b. If a patient is in the hspital, his/her chart must remain with the patient at all times and is nt t be remved frm the flr unless it is being sent with the patient fr a test r prcedure. c. Missing medical recrds put the hspital at high risk fr litigatin and lss f reimbursement. Please assist us in eliminating bth by nt remving charts frm designated areas. d. The Health Infrmatin Management Department is here t assist yu. If yu have any questins, please d nt hesitate t cntact us at extensin 4260.

5 The Sandra Atlas Bass Campus DOCUMENTATION GUIDELINES HIM DEPARTMENT Histry & Physical Examinatin: (Surce: Medical Staff Rules & Regulatins, Sectin D, Parts 1, 3, 5) Upn admissin, the Attending Physician, Dentist r Pdiatrist must dcument a medical Histry and Physical examinatin relevant t the patient s presenting signs and symptms, as well as summary nte including a prvisinal diagnsis, the patient s status and a preliminary treatment plan. The H&P shall include a screening uterine cytlgy smear n wmen 21 years r lder, unless the test is medically cntraindicated r has been dne within the past three years. A medical H&P is t be cmpleted within 24 hurs f admissin. The Emergency Rm H&P des nt suffice fr an inpatient admissin H&P. A cmprehensive H&P is required when the patient is admitted. A cmplete H&P, submitted t the Hspital frm an utside physician, may be acceptable if it has been perfrmed within seven days f admissin. An H&P may be dcumented by a Resident, Physician s Assistant, Nurse Practitiner, Attending Physician, r Dentist. If the H&P is written by a Resident, Physician s Assistant (PA), r Nurse Practitiner (NP), it MUST be cuntersigned by the Attending Physician, Dentist r Pdiatrist prir t the patient s discharge. When the H&P is nt cmpleted and signed by an Attending Physician, Dentist r Pdiatrist befre a surgical prcedure, THE PROCEDURE IS TO BE CANCELED (unless the risk f delay is verriding). Any entry made in the medical recrd by medical r dental students must be cuntersigned within 24 hurs by the Attending Physician, Dentist r Pdiatrist (as applicable), r by a supervising Resident at least at PGY level 2 and licensed as a physician (r dentist) in New Yrk State.

6 Advance Directives: (Surce: Patient Care Standard Plicy and Prcedure Patient Assessment: Initial and Onging ), als: Administrative Plicy and Prcedure Patient Advance Directives and Administrative Plicy and Prcedure DNR Orders Any patient ver the age f 18, including emancipated minrs, must be screened fr Advance Directives upn admissin. Patients must be asked if they have Advance Directives and the answer recrded in the medical recrd. All sectins pertaining t advanced directives are t be cmplete in the EHR. A cpy f the patient s directive(s) is t be placed in the paper recrd. Patients with capacity wh cme t the facility with a DNR previusly filed ut is a valid Advance Directives, s lng as the physician discusses the DNR with the patient and dcuments a nte and writes a DNR rder in the medical recrd. Patients withut capacity wh cme t the facility with a DNR previusly filled ut is valid as an Advance Directives, s lng as the physician fills ut the DNR frm stating Withut Capacity and has a cpy f the patient s DNR fr filing in the medical recrd. Physician Orders: (Surce: Medical Staff Rules & Regulatins, Sectin F, Parts 2, 3, 4) Regarding Orders (including telephne rders): Orders may be issued by practitiners apprpriately credentialed by the Medical Bard (i.e. Attending Physician, Dentist, Pdiatrist r Resident, Nurse Practitiner, Physician Assistant, Nurse Midwife r Nurse Anesthetist). Telephne Orders may be issued by: Medical Staff Graduate Staff Nurse Practitiner Certified Nurse Anesthetist Physician Assistant Nurse Midwives Telephne Orders are t be entered int the EHR by the receiving RN. Authenticatin Requirement: Telephne/Verbal Orders must be ready back fr verificatin, dated, and signed by the issuer as sn as pssible, but within 30 days f discharge. Exceptin: Orders fr Cntrlled Substances must be signed within 48 hurs (New Yrk State regulatins state that cntrlled substances rdered by a Physician Assistant must be signed within 24 hurs)

7 Regarding Verbal Orders: Verbal Orders may nly be issued during an emergency by a member f the Medical Staff, Graduate Staff r Nurse Midwife Verbal Orders can nly be accepted by: Allied Health Prfessins Adjunct Staff (see abve) A Pharmacist Registered Nurse Authenticatin Requirement: Telephne/Verbal Orders must be read back fr verificatin, dated, and signed by the issuer as sn as pssible, but within 30 days f discharge. Exceptin: Orders fr Cntrlled Substances must be signed within 48 hurs Restraints: refer t plicy Patient Care Services P&P Manual: Restraints Anesthesia: (N/A fr Pediatrics) Cnsent fr Anesthesia An Infrmed Cnsent discussin is dcumented n the secnd side f the Anesthesia Recrd. It is dcumented by the Anesthesilgist and must cntain a descriptin f the anesthesia risks, benefits, alternatives and the anesthesia plan. Reassessment prir t inductin f anesthesia This is nted n the secnd side f the Anesthesia Recrd where is specifically states Status change frm pre-p Operative: (N/A fr Pediatrics) An Infrmed Cnsent must be signed and dated by the patient and physician The Operative Reprt must be dictated immediately fllwing surgery and the Face Sheet indicatr signed when the reprt has been dictated A brief Operative Nte, cntaining the fllwing, must be recrded in the Prgress Ntes immediately fllwing surgery: Name f Surgen Name f First Assistant Name f Prcedure Pst-perative Diagnsis Specimen Remved H&P must be cuntersigned by the Attending Surgen preperatively if the H&P has nt been signed by an Attending Physician General: (Surce: Medical Staff Rules & Regulatins, Sectin E, Part 8) Any entry made in the medical recrd by medical r dental students must be cuntersigned within 24 hurs by the Attending Physician, Dentist r Pdiatrist (as applicable) r by a supervising Resident at least at PGY level 2 and licensed as a physician (r dentist) in New Yrk State.

8 Admissin Dcuments: A final diagnsis shall be recrded in the EHR, and signed by the respnsible physician at the time f discharge f all patients. A General Cnsent frm titled Cnsent Fr Admissin and Treatment must be signed and dated by the patient and witness. A dcument titled Authrizatin Fr Release f Infrmatin must be filled ut by the patient as this dcument, when signed by the patient, authrizes release f recrds. Discharge Summary (Final Summary): (Surce: Medical Staff Rules & Regulatins, Sectin E, Part 9) Residents and Allied Health Prfessinals Adjunct Staff, including Pdiatrists, Physician Assistants, Nurse Practitiners and Nurse Midwives (wh are apprpriately credentialed and privileged) may cmplete Discharge Summaries in the EHR, prvided that such Discharge Summaries are reviewed and cuntersigned by the apprpriate Attending Physician f recrd. Transfers between Sysset and Manhasset: Transfers between Sysset and Manhasset r Manhasset and Sysset are treated the same as any patient transferred frm ne unit f a hspital t anther unit in the SAME hspital. This is unique t Sysset and Manhasset because these facilities share ne perating license. The riginal medical recrd transfers with the patient, as wuld be the case with any in-huse transfer. The riginal medical recrd remains at the facility where the patient was ultimately discharged frm.

9 HEALTH INFORMATION MANAGEMENT DEPARTMENT Dear Dctr: Yur assistance is necessary in cmpleting the required elements listed belw. In rder fr the hspital t be cmpliant with the Jint Cmmissin n Hspital Accreditatin f Health Care Organizatins, we must have a current recrd f yur signature n file. Please fill ut the data belw and return this frm in the stamped, self-addressed envelpe prvided. Yur anticipated cperatin in this matter is appreciated. PRINT NAME: SIGN NAME: D yu utilize a signature stamp? yes n If yes, please cmplete the fllwing statement: I acknwledge that I am the nly individual with access t my signature stamp and am the nly ne authrized t use this stamp. ORIGINAL SIGNATURE: SIGNATURE IMPRINT: D yu utilize an electrnic signature? yes n If yes, please sign here t indicate that yu are the nly individual authrized t use yur electrnic signature: