Chart Completion Guidelines

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					                  Chart Completion Guidelines
          Chart Type = Observation/Ambulatory Surgery
                See General Instructions for additional guidelines

#   Document/                                    Guidelines
      Data
1   Admission      The admission status needs to be clearly documented in the physician
    Status         orders. If it is not clear whether the patients status is inpatient or
                   observation chart is to be referred to the HIM Systems Manager for
                   clarification. *Annotate: Date and initials when needing clarification of
                   patient status changes on the HIM track form
2   Admitting      The admitting physician is the physician responsible for admitting the
    Physician      patient to the hospital. This physician typically is responsible for
                   providing the History and Physical. The admitting physician may continue
                   the patient’s care through out the entire stay (see Attending Physician) or
                   may assign care to another physician
3   Attending      The attending physician is the physician responsible for managing the
    Physician      patient’s care during their hospital stay. This physician may be the same
                   physician who admits the patient or may take over the care after
                   admission. Typically this is the physician who provides the majority of the
                   care during the stay. The Attending Physician is the physician
                   responsible for providing the discharge summary
4   ED Record      The Emergency room physician is responsible for assessing the patient
                   and determines the appropriate treatment for the patient’s condition. This
                   physician must provide a dictated ED Note or can write his/her
                   assessment in the ED Record. If there is no written assessment, the ED
                   physician should be requested to dictate an ED Note
5   ED Triage      Patients presenting to the ED are immediately Triaged to determine the
    Notes          level of care needed. This documentation is entered into the Cerner ED
                   system. An interfaced or scanned copy of the ED Triage records should
                   be part of the record. Missing ED Triage notes should be obtained by
                   emailing the Nurse Manager in the ED Department (Sherry Smith)
6   History and    Every observation and surgery record is required to have an H&P present
    Physical/ OP   on the record within 24 hours of admission. H&Ps can be done up to 7
    Assessment     days prior to the admission for scheduled visits. If the H&P was
                   performed more than 7 days prior to the admission date, the physician
                   must indicate that the H&P was reviewed and document if there are any
                   updates. If the H&P was done more than 30 days prior to the admission
                   date, an entire new H&P was needs to be performed. The admitting
                   physician should be asked to dictate the H&P if one is not present or if
                   the H&P is older than 30 days. If the H&P is older than 7 days and there
                   is no documentation that it has been reviewed and updated, the physician
                   should be asked to provide an update, using a H&P update template

                   Consultations and pre-operative anesthesia assessments should not be
                   routinely substituted as an H&P. Physicians should not be asked if
                   they want to use another physician’s H&P as their own. The
                   admitting physician is responsible for providing the H&P for the case.
                   The only circumstance that the consultation may be used as the H&P is
                   when the physician providing the consult was truly the admitting/attending
                   physician on the case.

                   If the admitting physician instructs you to use another physician’s consult
                   or anesthesia assessment as the H&P:

                          Print the consult
                  Chart Completion Guidelines
          Chart Type = Observation/Ambulatory Surgery
#   Document/                                    Guidelines
      Data
                          Handwrite the title of H&P at the bottom of the report
                          Scan repot into the H&P folder
                          Add signature deficiency for admitting/attending physician

                   See Discharge Summary section (9) for further information

7   Spinal Exam    A spinal (musculoskeletal) exam is required by HFAP on all H&Ps
                   performed by D.O. physicians. Review the H&P to insure that one is
                   present in the physical section of the report. If one is not present add the
                   spinal exam template for the physician to complete. * See general
                   instruction note
8   Dictation on   Validate that the dictation assigned to this encounter belongs with the
    Correct        admission. Since the dictating physician does not need to provide the
    encounter      encounter number when the repot is dictated it is possible that the report
                   could be incorrectly assigned, especially if there are other visits that
                   occurred prior or subsequent to this visit. Read the dictation to determine
                   if the presenting signs and symptoms correspond with the other
                   documentation in the chart. Look for clues such as the patient’s mode of
                   arrive (i.e. through the ED) references to a prior visit, signs and symptoms
                   that correspond to other documentation in the chart. Questions should
                   be referred to the Chart Processing/Transcription Supervisor.

                   Dictated reports found to be attached to the wrong encounter should be
                   moved to the correct encounter. A copy of the report should be printed
                   and routed to the Transcription Assistant so that all other systems can
                   also be corrected
9   Discharge      The OP Assessment (short stay) notes purpose is to provide a
    Summary/       combination of an H&P and discharges summary for an observation
    OP             patient. Due to variations in how physician complete this the following
    Assessment     guidelines should be followed:

                          If the physician provides an OP Assessment that contains the
                           H&P documentation as well as a short summary of the patient’s
                           course of treatment, disposition and final diagnoses, no additional
                           documentation is needed.

                          If the physician provides an H&P that only includes the history
                           and physical, the physician should be asked to dictate a
                           discharge summary.

                          If the physician dictates an H&P that includes not only the history
                           and physical but also the course of treatment, disposition and
                           final diagnose, the physician does not need to provide any
                           additional information. However, the H&P needs to be printed
                           from imaging. The title of the report should be manually changed
                           to say “H&P/Discharge Summary” and then scanned in as a
                           discharge summary.

                   Note: ANE, AMB, GIE, and CAR cases only require an H&P unless
                   patient requires admission to observation status.
                   Chart Completion Guidelines
           Chart Type = Observation/Ambulatory Surgery
#    Document/                                    Guidelines
       Data
10   Progress       Each progress note must be signed by the author of the note. A
     Notes          signature deficiency should be assigned to any unsigned notes. A
                    progress note which contains an H&P should be labeled H&P and
                    scanned in under the H&P tab. If the Progress notes contains the
                    Discharge Summary label on the progress note and scan in as Discharge
                    Summary.
11   Physician      Each physician order must be signed by the physician giving the order.
     orders         This includes telephone and verbal orders. Assign a signature deficiency
                    to any un-signed orders. Orders written by Physician Assistant and
                    Nurse Practitioners must be co-signed by the responsible physician.
                    Check all pages of orders.
                    The following physician orders have exceptions for signature
                    requirements:
                          Standing orders do not require signatures: i.e. pneumonia
                             vaccine;
12   Consultants    Physicians providing consultative services on a case should provide a
                    dictated or hand written consultation. Review the physician orders to
                    determine if any physician has been asked to provide a consult on the
                    patient’s case. If there is not a consultation on the record, the physician
                    asked to provide a consult should be assigned a dictate deficiency
13   Procedure      Procedures performed in the operating room, cath lab, endoscopy lab,
     Reports        bronchoscopy lab should have a dictated operative report. Review the
                    nursing operative notes, anesthesia records, patient monitoring flow
                    sheets, cardiac cath technician notes, and consents to determine if and
                    how many procedures were performed. Validate that there is a dictated
                    report for every procedure performed. If the report is not present, request
                    that the operating physician dictate the report.
14   Anesthesia     Determine if an anesthesiologist was on the case by looking at the
     Record         dictated procedure note and/or nursing operative record. If so, verify that
                    there is a corresponding anesthesia record for the procedure. Review the
                    anesthesia record to insure that it has been signed by the
                    anesthesiologist. Surgery should be contacted via email for missing
                    anesthesia records. (See contact list)
15   Surgery        Procedures performed in the operating room must have a Surgery
     Nursing        Nursing Record. For each procedure performed, verify that a surgery
     Record         nursing record is present. Missing reports should be obtained by
                    emailing Surgery Department (See contact list)

                    Note: C sections should have a C section delivery record which comes
                    from the OB TraceView system. Contact MBCU (Annette Saylor) if the
                    patient had a C-Section and this record is not present on the record
16   Cardiac Cath   Every procedure performed in the Cath Lab should have cardiac cath lab
     Notes          technical notes. Verify they are present for each procedure. Contact
                    cath lab via email to obtain any missing report (See contact list)
17   Pathology      Procedures that result in tissue being removed for pathological evaluation
     Report         should have a pathology report present on the case. To determine if a
                    pathology report is needed, review the procedure report for the following
                    terms:
                         Biopsy
                         Excision
                         Removal
                         -ectomy
                  Chart Completion Guidelines
          Chart Type = Observation/Ambulatory Surgery
#    Document/                                   Guidelines
       Data
                         Resection
                   Also the nursing operative report has a section that lists any specimens
                   removed. The Patient Monitoring Flow sheet also has a check box
                   indicating if specimens were sent to pathology.

                   If specimens were removed and no pathology report is present, contact
                   the lab via email to obtain a copy of the report
18   Radiology     Radiology reports should be present for any radiology exams ordered.
     Reports       Review the physician orders to determine if radiology exams were
                   ordered. Review the radiology repots to verify that there are reports for
                   the tests ordered. Contact Radiology via email for any missing reports
                   (Julie Garrett)
19   Lab Reports   Most inpatient charts will have lab tests ordered. Validate that laboratory
                   reports are present on the record. If there are no lab reports, review the
                   physician orders to determine if any were ordered. If lab was ordered
                   contact Lab via email to obtain the missing reports
20   Other         Review the physician orders for any additional test that were ordered,
     ancillary     EKGs, neurology, vascular, etc. If the corresponding reports are not
     reports       present, contact the source department for a copy of the report via email
21   OB Short      OB Observation cases should have a short stay note, OP Assessment
     Stay          and or H&P/DSUM. However since some of these visits are very short in
     Note/H&P/     time, the physician may provide a summary of the visit in a progress note.
     Discharge     If this occurs the progress note is sufficient documentation for the case.
     Summary       The physician does not need to provide any additional documentation. If
                   there is no progress note or dictated note, the physician should be asked
                   to dictate an OP Assessment.

22   OB L&D        These notes are interfaced from Invision --- if they are not present contact
     notes         MBCU via email to obtain a copy (See contact list)
23   OB Admit      These notes are interfaced from Invision --- if they are not present contact
     Record        MBCU via email to obtain a copy (See contact list)
24   OB Flow       These notes are interfaced from Invision --- if they are not present contact
     Chart         MBCU via email to obtain a copy (See contact list)

				
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