Medical Chart Form Template by sgt19112

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    Documentation Requirements
       at Time of Admission

 H&Ps are to be dictated within 24 hours and
  signed by the attending physician
 Brief handwritten admit notes are entered in
  the paper record or directly keyed into the
  progress notes on the WebCIS
    Documentation Requirements
     in the Peri-operative Period

 Operative Reports are to be dictated
  immediately after surgery and electronically
  signed by the attending physician
 Brief Operative Notes are to be completed
  and filed in the medical record immediately
  after surgery
    Documentation Requirements
        at time of discharge
   Final Discharge Notes and Orders are to be
    completed at discharge on all patients placed in a
    bed and admissions less than 48 hours are to be
    signed by the attending physician
   Discharge Summaries are to be dictated at
    discharge for:
    – admissions > 48 hours
    – deaths (include date and time of death)
    – AMA’s (against medical advice)
   Discharge Summaries are to be electronically
    signed by the attending physician
    Documentation Requirements

   Verbal Orders are to be signed and dated ASAP
   No white out or obliterations are made in the
    record. To make corrections, draw one line, write
    “error”, sign and date correction
   All entries in the medical record must be
    authenticated with name, title, ID number and
    dated and MUST BE LEGIBLE!
   Must sign and enter corrections/changes to
    dictated documents electronically
    Documentation Requirements
 All inpatient discharges must have all
  documentation requirements completed
  within 28 days post discharge
 Clinic notes must be dictated within 24
  hours and electronically edited and signed
  within 5 days of service
Incomplete Documentation
Incomplete Documentation
Day of week Topic        Addressees

Fridays     List of      Providers
Thursdays   Executive    Chairs and
            Summary      Residency
            and Chart    Training
            Status       Directors
Incomplete Documentation
Day of week Topic        Addressees

Mondays-    List of      Chairs
Fridays     Undictated   Residency
            Operative    Directors
Tuesdays    Undictated   Chairs
            Discharge    Residency
            Summary      Directors
 Administrative
             of Pending
 Notification
 Suspension provided on
 Mondays to:
  –Residency Training Diretor
    Administrative Suspension
 At least one 28-day incomplete record and
  available to the provider for at least a week
 Provider has not attempted to complete
  it/them in the past week
 Provider/Department has not notified the
  MIM Department of extenuating
  circumstances (sick, vacation, etc.)
   Administrative Suspension
 Day1 (Fridays) – MIMD
 Determines Eligibility and
 Provider contacted by MIMD,
 House staff office, or Clinical
   Administrative Suspension
 Day 4 (Mondays) - Notification
 of Pending Suspensions to:
 Residency Training Director
    Administrative Suspension
 Day 6 (Wednesdays) – Notifications of
  Final Suspensions to:
   Provider
   Clinical Department Chair
   Residency Training Director
   Others
 Signed by Chief of Staff and Hospitals’
  Chief Operating Officer
    Until Suspension Records are
 Cannot admit new patients, schedule new
  surgical procedures, provide care to patients
  in ED nor schedule new clinic appointments
 Cannot provide care to patients in the E.D.
 House Staff Physicians are removed from
  all clinical activities and placed on annual
 Other penalties as imposed by the
  individual clinical departments and services
    On-going Activities Related to
    Chart Completion/suspension
   Weekly notification letters are mailed each Friday
    to all providers with one or more incomplete
    record. Notification letters include all incomplete
    records with an asterisk (*) indicating those charts
    28 days and older
   The MIM Committee Chairman submits, upon
    request and during the reappointment process, any
    provider who has had 1 or more pending/final
    suspensions within a 12-month period. This
    information is utilized by the Department Chairs
    for consideration in credentialing reviews
    How To Avoid Suspension
 Call 6-4425 for advance pulling of
 Come by the Workroom and complete
  ESA’s at least weekly
 Notify the Workroom when away on
  vacation or extended leave and
 complete all records just prior to
   How To Avoid Suspension

 Complete   inpatient documentation
  on the unit at the time or before the
  patient is discharged
 Enforce documentation
  requirements of the residents and
  monitor their performance
         Transcription Services
 Inpatient:
–   Dial 6-1111 on any touch tone phone
–   Enter
    physician ID code without check
    one-digit work type
    Patient’s medical record number
      without the check digit
      Transcription Services

          Work Types:
 Inpatient
   1= DC Summary
   2= Operative Report
   4=Stat Report (transfers only)
   5=History & Physicals
   3=Normal OB Delivery Notes
        Transcription Services
   Inpatient Auto faxing
    – Dictate Referring/Primary Care
      provider information
    – Faxed from MIM Dept.
      Computerized fax system
      Immediately following transcription
      or mailed if fax number not available
        Transcription Services
 Outpatient:
–   Must dictate all clinic notes
    through one of the approved
     UNCHCS contracted service
     Internally utilizing Chartscript
      within the Department
       Transcription Services
 Utilize the approved template for new
  patient visits and established patient
 Documents are transcribed within 24
  hours and auto faxed to referring
  physician upon editing and electronic
  signature on the Clinical Information
  System (CIS)
    Paper Chart Organization
          Universal Chart Order –
 Inpatient
 same order post discharge as on the
  –Dividers list the order of the
   documents to be filed
  –Must be kept in that order on the
            Chart Organization
   Documents on Clinical Information System
    (CIS) are not printed and filed in the paper chart:
      History &      Laboratory     Respiratory
      Physicals      Reports        Therapy
      Discharge      Radiology      Direct Entry
      Summaries      Reports        Progress
      Operative      Pathology      Clinic Notes
      Reports        Reports
           Chart Organization
   Circulating Record System
    – Multiple volumes are streamlined into
      one volume that has the clinical
      documents (key) in it, which circulates
    – Other volumes that store the “bulk” (non-
      key) which do not circulate
        Chart Organization
 Key Documents –
  – ED Record
  – Consultations
  – Anesthesia Record
  – EKG Reports (all others are on CIS)
  – Outpatient documents
       Chart Organization

 Non-Key Documents
  – Flow Sheets
  – Medication Administration Records
  – Handwritten Physician Progress
  – Nurses’ Notes
  – Medical Orders
Chart Organization – Circulating
        Record System
   Records of Discharged Patients:
–   Original documents are filed in temporary
    workroom folders for completion
–   Copies of incomplete admissions where the
    documents are not on CIS are available
    upon request by calling 6-4425
–   Original documents are filed in the
    permanent circulating volume following
    chart completion
Accessibility and Management of
 Charts and Patient Information
 Access  to Patient Information in paper
  or CIS must be made on a “need to
  know” basis for performing job duties
 Charts must not be removed from
  clinic or unit or hospital property
Accessibility and Management of
 Charts and Patient Information
 Charts must be returned from clinic
  within 24 hours or from the unit the
  day post discharge
 Return charts to clinic front desk when
  patients have multiple appointments on
  the same day to be transferred
 Release of Medical Information
          and Research
 Requests   for patient information
  received from outside requesters such
  as insurance companies, attorneys,
  patients, etc. must be handled by the
  Release of Information area of the
  MIM Dept.
 Charts requested for the purposes of
  quality assessments and research
  projects are not to be removed from the
  Research are of the MIM
 Release of Medical Information
          and Research

 Requests  for computerized patient
  data, paper charts, and access to patient
  information on the CIS for the
  purposes of research require
  appropriate completion of specific
 Obtain forms at
 Administrative and General – 6-1225
 Physicians’ Workroom – 6-4425
 Chart Management and Retrieval – 6-2312
  (24 hours a day/7 days per week)
 Inpatient Transcription – 6-4797
 Outpatient Transcription – 6-2525
 Release of Medical Information – 6-2336
 Research – 6-5655

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