Safekeeping of Medical Records Guidelines by khi66344


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									                         CREIGHTON SAINT JOSEPH MEDICAL STAFF
                                MEDICAL RECORDS POLICY

  I.       Responsibility for Medical Records:

           A.   The attending practitioner is responsible for a complete and legible medical record on
                each patient which documents justification for the hospital stay. Illegible signatures must
                be supplemented by printed name.

           B.   Entries by House Staff and Mid-Levels (as an agent for in and in the name of their
                supervising/collaborative physician) shall include the history and physical examination,
                operative reports, orders, progress notes, consultations, and discharge summary.

           C.   Medical student entries on the medical record shall be limited to progress notes.

           D.   Care provided by all caregivers shall be documented as appropriate in the medical
                record. The Forms Committee will approve all forms used to document this information.
                Guidelines for documentation will be the responsibility of the department providing

           E.   All dictated reports must have:
                1.      Patient Name
                2.      Account Number
                3.      Date of Admission, or date of consultation, or date of operation
                4.      List of physicians for sending copies
                5.      Type of report.

           F.   Failure to comply with these regulations may result in suspension of admission privileges
                after the practitioner has been advised of his delinquency, as outlined in the Policy on
                Appointment, Reappointment and Clinical Privileges.

           G.   Inappropriate remarks shall not be dictated or written in the medical record.

 II.       Contents of the Medical Record shall include:

           A.   Identification data.

           B.   Admitting diagnosis.

           C.   Principal diagnosis
                       (1)    Secondary diagnosis

           D.   Principal procedure
                       (1)    Secondary procedure

           E.   Discharge summary signed and dated by the attending physician

           F.   Discharge order form signed and dated by a physician.

           G.   History and physical signed and dated by the attending physician.

           H.   Operative report(s) (if applicable) signed and dated by the attending

           I.   Consultation report(s) (if applicable) signed and dated by the consulting

           J.   Orders signed, dated, and timed.

           K.   Progress notes signed, dated and timed.

           L.   Diagnostic and therapeutic orders signed, dated, and timed.

           M.   Diet and/or nutritional support orders signed dated and timed.

           N.   Clinical observations including results of therapy.

           O.   Reports of procedures, tests and their results.

           P.   Autopsy reports to include provisional anatomical diagnoses and completed record
                (when applicable).

           Q.   American Joint Commission on Cancer staging on newly diagnosed cancer must
                recorded on the medical record by the managing physician on initial diagnosis. These
                may be clinical or pathologic, whichever is appropriate. Both are not required.
                Retreatment staging may be reordered at the discretion of the physician.

           R.   Patient Coding Sheet.

           S.   The current obstetrical record will include a complete prenatal record. The prenatal
                record shall be a legible copy of the attending practitioner‟s office record transferred to
                the Hospital before admission.

III.       History and Physical:

           A. All patients put to bed, whether inpatient admission or observation shall be required to have
               a complete history & physical documented on the medical record.

           B.   Time Requirements: A medical history and physical must be completed within 24 hours
                of admission.

           C.   If the history and physical is completed 30 days prior to the admission, update to the H&P
                must be documented at the time of admission or prior to surgery/invasive procedure.
                The update can be “no changes.” The update can be documented in the progress notes
                or on an H&P form.

           D.   The H&P completed by a practitioner who is not a CUMC Medical Staff member will be
                accepted as long as it meets the completion and content criteria as outlined in this policy
                III (c) and (d). The review and updating of that H&P as outlined in section III (c) will
                constitute the signing of that H&P.

           E.   Content of History and Physical:

                               (a)    Chief complaint, admitting diagnosis
                               (b)    Present illness
                               (c)    Past history (including allergies, current medications and
                               (d)    Relevant family history and social history
                               (e)    Review of systems
                               (f)    Pertinent Physical Exam
                               (g)    Treatment plan (Plan of Care)
                               (h)    Impression

           F.   Records Permitted in Lieu of Admission History and Physical:

                (1)    A comprehensive consultation, which includes a history and physical, may be
                       used in lieu of a history and physical examination.

           G.   Requirement for History and Physical before Surgery/Invasive Procedure:

                (1)    When the history and physical examination are not recorded before surgery or
                       invasive procedure, the procedure shall be cancelled.

                (2)     If the attending physician or surgeon states in writing that such delay would be
                        detrimental to the patient, the procedure can be performed, however, the History
                        and Physical Examination shall be dictated within 24 hours.

                (3)     For “pre-operative patient” one MUST include a statement regarding discussion of
                        risks, benefits, options and potential complications of the procedure, as well as
                        blood transfusion, if applicable.

           H.   Outpatient/Ambulatory Surgery Documentation: It is the surgeon's ultimate
                responsibility to assure that an adequate preoperative assessment, appropriate to the
                planned procedure is completed and documented.

                Minimum requirements for Outpatient Surgical Pre-Operative Assessments are as

                A history is required regardless of the type of anesthesia planned and/or given,
           as well as when no anesthesia is given. The history must at a minimum include
           documentation of:

                1.      indication/symptoms for surgical procedure;
                2.      a list of current medications and dosages;
                3.      any known allergies, including medication reactions;
                4.      existing co-morbid conditions, if any.

                 The extent of documentation required in the physical examination is to be
           reflective of the type of anesthesia planned and/or given according to the
           following hierarchy.

                        No Anesthesia or topical, local or regional block:

                        (a)    assessment of mental status and,
                        (b)    an examination specific to the procedure proposed to be performed and
                               comorbid conditions.
                        (c)    Vital signs (TPR & BP)

                        IV Sedation
                        (c)   a , b and c above and
                        (d)   examination of heart and lung by auscultation.
                        (e)   ASA Physical Status Classification.

                        General, spinal or epidural anesthesia

                        (e)    a, b, and d above and
                        (f)    assessment and written statement about the patient's general condition.

IV.        Progress Notes:

           A.   Pertinent progress notes shall be recorded, timed and dated at the time of observation.

           B.   It is the responsibility of a staff physician or Chief Resident/Fellow to daily countersign
                the house staff or medical students progress notes, or to indicate his/her involvement in
                care of a patient with a note of his/her own. The day of discharge may be excluded.

                     1. Mid-levels as an agent in and in the name of their supervising/collaborative
                     physicians are exempt from this requirement.

           C.   Whenever possible, each of the patient's clinical problems should be clearly identified in
                the progress notes and correlated with specific orders as well as results of tests.
                Progress notes shall reflect the response of the patient to treatment.

V.         Procedures at bedside

           A. When a procedure is performed at bedside, the physician must assure that a procedure
                note is entered into the medical record. Minimally, this note must state rationale for
                procedure, and status of the patient post procedure. This note must be dated, timed and

   VI.    Operative Reports must be dictated on the day of procedure.

          A.    The individual who is responsible for the patient shall record a preoperative diagnosis
                prior to surgery.

          B.    All operative reports must contain:
                1.     Date of operation or procedure
                2.     Preoperative diagnosis
                3.     Postoperative diagnosis
                4.     Operative title/procedures performed
                5.     Surgeon name
                6.     Assistant surgeon
                7.     Anesthesia type
                8.     Indications and findings
                9.     Procedures detail (technical description)
                10.    Laceration/wound – (length and width)
                11.    Specimens removed
                12.    Sutures/drains – type of closure (e.g. layered, intermediate closure)_
                13.    Estimated blood loss (document replacement if given)
                14.    Disposition/condition
                15.    Complications, if any

           C.   The postoperative summary or note shall be written in the medical record by the surgeon
                immediately following surgery.

VII.       Consultations:

           A.   All requests for consultations shall be documented in the medical record.

           B.   Consults should include reason for consultation and date of consult. Consult reports shall
                be signed and dated by the consulting physician. Consults handwritten in the progress
                notes must be authenticated by the attending physician if he/she did not provide the

VIII.      Orders for Treatment of Patients:

           A.   All orders for treatment of patients shall be in writing.

                (1)    The practitioner's orders must be written clearly, legibly and completely.

                (2)    Orders which are illegible or improperly written shall NOT be carried out until
                       rewritten or understood by the nurses.

                (3)    All orders shall be dated and timed.

                (4)   Staff practitioners may permit appropriately licensed house staff members to write
                      orders and conduct care for their patients under supervision. Granting this
                      privilege       to house staff members does not prohibit orders to be written by the
                      attending staff practitioner or without permission of the house staff member.

                       (a)    Nonparticipation in this practice by a staff practitioner shall not in
                              itself be the basis for privilege or membership sanctions to be used against
                              the practitioner.

                   (5)    Blanket orders for medications and treatments are unacceptable. Medication and
                          treatment orders must be specific. The terms Resume, "Renew", "Repeat" and
                          "Continue Orders" are not acceptable. All medication orders must include the
                          medication name, dosage, frequency, and route of administration. The use of “on
                          call” or „prn” with medications shall be qualified in terms of condition or situation
                          for which the medication is prescribed, and time or time interval or maximum dose
                          per time period (e.g. PRN pain, PRN fever). Orders without his component are
                          not considered valid and will not be executed.

                   (6)    All previous orders are cancelled when a patient goes to the Operating Room.
                          New orders are required post operatively.

                    (7)     Medication orders must be written or reconciled at the time of admission and
                transfer or discharge.

          B.       Telephone Orders: Only licensed, registered or credentialed personnel may take
                         telephone orders, which relate specifically to their scope of practice.

                   (1)    Medical Assistants may call with verbal orders from their physicians for tests.

                   (2)    Any professional who receives a telephone order must document the order in the
                          patients medical record. The healthcare professional taking the telephone or
                          verbal order will document “WRBO” for written read back order.

           C.      Preprinted Orders when applicable, shall be completed in detail on the order sheet of the
                   patient's record, dated, signed and timed by the practitioner. All preprinted orders must
                   be approved the Forms Committee.

           D.      All discharge orders for inpatients and observation patients shall be accompanied by
                   orders for discharge medications (or no medication). The discharge medication order
                   shall include name, dosage and frequency of all medications the patient is to take at
                   home. In addition, the discharge order shall include activity limitations, diet and follow-up
                   care instructions. It is mandatory that a discharge form, including reconciliation of
                   medication, be completed. "Same med" or other similar vague orders are not
                   appropriate and shall not be accepted.

IX.        Reports of Procedures, Tests and Their Results:

           A.      Pertinent reports shall be recorded, dated and timed.

           B.      Preliminary reports will not be placed on the chart with the following exceptions:

                          1. Echocardiograms preliminary reports.
                          2. Radiology preliminary reports.
                          3. Autopsy provisional reports

X.         Discharge Summary

           A.      All patients placed to a bed, whether inpatient admission or observation, shall be
                   required to have a completed discharge summary on the medical record. House staff are
                   expected to complete the discharge summary the day the patient is discharged.
                   However, in anticipation of patient discharge or transfer to another facility, the discharge
                   summary may be dictated within 24 hours of the actual discharge from the facility. If the
                   patient‟s hospitalization is extended beyond the expected discharge or there is a change
                   in patient status prior to the patient‟s discharge, a discharge addendum will be required.

           B.      Content of Discharge Summary:

                   1.     FINAL DIAGNOSIS which is the condition found to be responsible for the
                   2.     Date of Admission and Discharge
                3.     Admitting Diagnosis or Chief complaint
                4.     History of present illness
                5.     Significant Findings
                6.     Hospital Course (include procedures performed, treatment rendered)
                7.     Complications, if any
                8.     Discharge instructions (include activity, diet and medications)
                9.     Condition on Discharge
                10.    Disposition (if transferred, state level of care the receiving facility will provide, i.e.,
                       rehab, acute care, psych, etc.)

           C.   A discharge summary shall be authenticated by the attending physician.

 XI.       Authentication of Entries in Patient's Medical Record:

           A. Clinical entries in the patient's record shall be accurately dated and authenticated.
              Authentication means to establish authorship by written signature, identifiable initials or
              computer key.

                1.     Authentication of records post discharge will be accomplished utilizing electronic

           B.   Telephone orders for DNR and Restraints must be authenticated and dated/timed by the
                licensed physician within 24 hours. Telephone order must be signed, dated and timed
                with 48 hours. All other orders must be authenticated and dated/timed within 48 hours
                of patient discharge.

           C.   The history and physical, operative reports, consultations, and discharge summaries
                must be validated and countersigned by the appropriate staff physician within thirty days
                of patient discharge.

           D.   The use of a rubber signature stamp is prohibited.

           E.   Electrocardiograms over-reads may be authenticated by the Cardiologist's typed name

           F.   If an ordering physician is unable to authenticate his/her verbal order (i.e. ordering
                physician is off duty), it is acceptable for a covering physician to co-sign the verbal order
                of the ordering physician. The signature indicates that the covering physician assumes
                responsibility for his/her colleague‟s orders as being complete, accurate and final.

  XII.     Symbols and Abbreviations:

         A. The use of abbreviations is limited and only standard abbreviations are to be considered
            when documenting in any written notes or orders in the medical record.

         B. The use of abbreviations in the medical record mist be viewed within the context of the
            documentation, as many abbreviations are used for more than one item, e.g. RA for
            rheumatoid arthritis or right atrium. When a definition of an abbreviation is in doubt, the
            hospital relies on the following reference for guidance: Medical Abbreviations, Twelfth
            Edition by Neil M. Davis.

         C. When referring to items from the Periodic Table of Elements, the standard letter
            designations are acceptable in the medical record. Additionally, chemical compounds
            that are most often used may be written in their standard letter designations, e.g. KCl for
            potassium chloride.

         D. B. The following abbreviations/dose designations are NOT allowed during medication order
         Abbreviation/Dose          Word or Phrase                 Intended Meaning/               Correction
           Designation                                              Misinterpretation

          All Apothecary        Examples:                                                  Use metric system
         symbols                dram                     symbol for dram misread
                                minim                    for “3”
         AU                     Aurio uterque            ou (oculo uterque- each           Spell out :Both ears
         AS                     (each ear) Left ear      eye)                              Left ear
         AS                     Right ear                Mistaken for each other           Right ear
         OU                     Both eyes                Don't use these                   Both eyes
         OS                                              abbreviation
                                Left eye                                                   Left eye
                                Right eye                                                  Right eye

         IU                     International Units      Mistaken for 'IV'                 Spell out units
         U                      Unit                     Mistaken as a zero (0)            Spell out the word
         g                     microgram                Mistaken as 'mg' milligram        Use mcg
         MS                                              Confused for one another.
                                                         M                                 Write “morphine
         MSO4                   Morphine Sulfate                                           sulfate” or
         MgSO4                  Morphine Sulfate                                           “magnesium sulfate”
                                Magnesium Sulfate
         q.d. or Q.D.           Every day or             Mistaken as q.i.d.,               Write “daily”
                                Once daily               especially if the period
                                                         after the “q” or the tail of
                                                         the “q” is misunderstood
                                                         as an “i.”
         q.o.d. or Q.O.D.       Every other day          Misinterpreted as “q.d.”          Write “every other
                                                         (daily) or “q.i.d. (four times    day”
                                                         daily) if the “o” is poorly
         qn                     nightly or at            Misinterpreted as “qh”            Use “nightly.”
                                bedtime                  (every hour).

         Zero after decimal     1.0 mg                   Do NOT use a trailing zero        1mg
         point                                           for doses expressed in
         (Trailing zero)                                 whole numbers.
                                                         One milligram mistaken as
                                                         ten milligrams when the
                                                         decimal is not seen
         Zero before            .5mg                     ALWAYS use a leading              0.5mg
         decimal dose                                    zero before a decimal for
         (Leading zero)                                  doses less than whole
                                                         One-half milligram
                                                         mistaken as five milligram

XIII.      Release of Medical Records:

           A.   Records may be removed from the Hospital's jurisdiction and safekeeping only in
                accordance with a court order, subpoena or statute. All records are the property of the
                Hospital and shall not otherwise be taken away without permission of the Chief Executive
                Officer or Hospital Compliance Officer.

           B.   Unauthorized removal of records from the Hospital is grounds for suspension of the

                 practitioner for a period to be determined by the Medical Policy Board.

XIV.       Alteration of Records: A single line shall be drawn through each line of inaccurate
           material making certain that it is still legible. All deletions shall be marked "error", dated and
           initialed. A correction shall be entered in chronological order making sure to indicate which
           entry the correction is replacing. In any questionable situations, corrected notations shall be
           witnessed by a colleague.

 XV.       Removal of Material from Records:

           A. Absolutely nothing shall be removed from the Medical Record except when
           preliminary reports are replaced with final reports.

XVI.       Incomplete Medical Records:

           A.    Medical Staff members will be suspended for failure to complete medical records within
                 the designated time. House staff will lose vacation days for failure to complete medical
                 records within the designated time. Every two weeks warning letters will be sent to
                 physicians as a reminder that they need to correct these deficiencies. If the records
                 remain incomplete for seven days after notice the suspension sequence is activated.
                 The practitioner‟s CUMC identification badge will be suspended along with the
                 practitioner‟s privilege to utilize the parking garage and medical staff lounge/dining room.

           B. Failure to complete medical records for a second week will result in continued suspension
              of a practitioner‟s CUMC identification badge and will be expanded to include clinical
              privileges and rights to admit or schedule patients for surgery, or to provide any other
              professional services.

           C. Failure to complete records for a third week will result in continued suspension of a
              practitioner‟s CUMC identification badge and clinical privileges and right to admit or
              schedule patients for surgery, or to provide any other professional services. The Vice
              President of Medical Affairs will be notified of the practitioner‟s continued suspension.

                (1) Delinquent records for house staff members will be re-assigned to the attending
                    physician for completion. Once the records has been referred to the attending
                    physician for completion it will not be reassigned to the responsible house staff
                    members. A letter will be sent to the house staff member‟s Program Director outlining
                    their failure to complete their medical record responsibilities. Medical records left
                    incomplete by a house staff member due to illness, leave of absence or successful
                    completion of the program will be referred to the attending physician for completion,
                    but will not be reported to the Program Director.

           D.    Failure to complete these records four weeks after the date ot suspension shall be
                 deemed a voluntary resignation of the practitioner's Medical Staff membership. A
                 practitioner whose clinical privileges are automatically suspended, or who have resigned
                 Medical Staff membership for failure to complete medical records, shall not be entitled to
                 procedural rights as set forth in the Policy on Appointment, Reappointment or Clinical

           E.    Special Circumstance:

                 (1)    Practitioners/mid-levels who are ill will not be placed on the overdue list if the
                        Health Information Department is notified.

                 (2)    Practitioners/mid-levels who are on vacation or out-of-town will not be placed on
                        the overdue list if the Health Information Department is notified advance. The
                        clock for record completion restarts when the physician returns.

                 (3)    House staff on rotation at other facilities will be expected to complete all record
                        deficiencies on schedule.

                  (4)   When the Senior Vice President for Medical Affairs determines that extenuating
                        circumstances exist, a practitioner/s/mid-level‟s records may be signed by his
                        partner or other members of his professional corporation.

         E. Filing incomplete medical records
                (1)    After 90 days from initial suspension, medical records which have not been
                       completed by the responsible Medical Staff members will be filed incomplete.
                       This will be done with the approval of the appropriate Department Chairperson.
                       A notation of the incomplete records will be made in the patient‟s records and the
                       practitioner‟s Medical Staff credentials file. Completion of these records will be
                       required prior to re-instatement of Medical Staff privileges.

XVII.      Video Tapes/Images: All non-diagnostic videotapes/images made for educational or research
           purposes are the property of the Medical Staff member performing the procedure. The
           Medical Staff member is responsible for the storage, retrieval and retention of the
           videotapes/images in accordance with applicable State law.

         First Revision: October 19, 1981
         Second Revision: December 20, 1982
         Third Revision: March 26, 1985
         Fourth Revision: April 7, 1986
         Fifth Revision: April 27, 1987
         Sixth Revision: November 23, 1987
         Seventh Revision: January 12, 1990
         Eighth Revision: June 14, 1991
         Ninth Revision: August 26, 1991
         Tenth Revision: May 25, 1993
         Eleventh Revision: November 14, 1993
         Twelfth Revision: June 27, 1995
         Thirteenth Revision: September 16, 1997
         Fourteenth Revision: April 21, 1998
REVISED: Fifteenth Revision: March 21, 2000
         Sixteenth Revision: May 20, 2001
         Seventeenth Revision: May 15, 2003
         Eighteenth Revision: August 19, 2003
         Nineteenth Revision: December 17, 2003
         Twentieth Revision: August 18, 2004
         Twenty-first Revision: December 14, 2005
         Twenty-second Revision: March 22. 2006
         Twenty-third Revision: March 25, 2007
         Twenty-fourth Revision: November 28, 2007
         Twenty-fifth Revision: March 19, 2008
         Twenty-sixth Revision: June 25, 2008
         Twenty-seventh Revision: September 28, 2008

Medical Executive Committee                                      March 3, 2009
                                    President                    Date

Governing Board                                                March 25, 2009
                                     CEO                        Date


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