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DOCUMENTATION, CHART COMPLETION, AND CHART MANAGEMENT

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DOCUMENTATION, CHART COMPLETION, AND CHART MANAGEMENT JONI PERRY, RHIA, DIRECTOR MEDICAL INFORMATION MANAGEMENT Release of Medical Information and Research Requests ... – PowerPoint PPT presentation

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Title: DOCUMENTATION, CHART COMPLETION, AND CHART MANAGEMENT


1
DOCUMENTATION, CHART COMPLETION, AND CHART
MANAGEMENT
  • JONI PERRY, RHIA, DIRECTOR
  • MEDICAL INFORMATION MANAGEMENT

2
Documentation Requirementsat Time of Admission
  • HPs 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

3
Documentation Requirementsin 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

4
Documentation Requirementsat 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 gt 48 hours
  • deaths (include date and time of death)
  • AMAs (against medical advice)
  • Discharge Summaries are to be electronically
    signed by the attending physician

5
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

6
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

7
Incomplete Documentation Notifications
8
Incomplete Documentation Notifications
Day of week Topic Addressees
Fridays List of incomplete records Providers
Thursdays Executive Summary and Chart Status Report Chairs and Residency Training Directors
9
Incomplete Documentation Notifications
Day of week Topic Addressees
Mondays-Fridays List of Undictated Operative Reports (email) Chairs Residency Directors
Tuesdays Undictated Discharge Summary Reports Chairs Residency Directors
10
  • Administrative Suspension Process

11
  • Notification of Pending Suspension provided on
    Mondays to
  • Provider
  • Chair
  • Residency Training Diretor

12
Administrative Suspension Criteria
  • 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.)

13
Administrative Suspension Process
  • Day 1 (Fridays) MIMD Determines Eligibility and
    Provider contacted by MIMD, House staff office,
    or Clinical Department

14
Administrative Suspension Process
  • Day 4 (Mondays) - Notification of Pending
    Suspensions to
  • Provider
  • Chair
  • Residency Training Director
  • Others

15
Administrative Suspension Process
  • 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

16
Until Suspension Records are Completed..
  • 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 leave
  • Other penalties as imposed by the individual
    clinical departments and services

17
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

18
How To Avoid Suspension
  • Call 6-4425 for advance pulling of charts
  • Come by the Workroom and complete ESAs at least
    weekly
  • Notify the Workroom when away on vacation or
    extended leave and complete all records just
    prior to leaving

19
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

20
Transcription Services
  • Inpatient
  • Dial 6-1111 on any touch tone phone
  • Enter
  • physician ID code without check digit
  • one-digit work type
  • Patients medical record number without the check
    digit

21
Transcription Services
  • Inpatient Work Types
  • 1 DC Summary
  • 2 Operative Report
  • 4Stat Report (transfers only)
  • 5History Physicals
  • 3Normal OB Delivery Notes

22
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

23
Transcription Services
  • Outpatient
  • Must dictate all clinic notes through one of the
    approved systems
  • UNCHCS contracted service
  • Internally utilizing Chartscript within the
    Department

24
Transcription Services
  • Utilize the approved template for new patient
    visits and established patient visits
  • Documents are transcribed within 24 hours and
    auto faxed to referring physician upon editing
    and electronic signature on the Clinical
    Information System (CIS)

25
Paper Chart Organization
  • Inpatient Universal Chart Order same order post
    discharge as on the unit
  • Dividers list the order of the documents to be
    filed
  • Must be kept in that order on the unit

26
Chart Organization
  • Documents on Clinical Information System (CIS)
    are not printed and filed in the paper chart

History Physicals Laboratory Reports Respiratory Therapy Reports
Discharge Summaries Radiology Reports Direct Entry Progress Notes
Operative Reports Pathology Reports Clinic Notes
27
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

28
Chart Organization
  • Key Documents
  • ED Record
  • Consultations
  • Anesthesia Record
  • EKG Reports (all others are on CIS)
  • Outpatient documents

29
Chart Organization
  • Non-Key Documents
  • Flow Sheets
  • Medication Administration Records
  • Handwritten Physician Progress Notes
  • Nurses Notes
  • Medical Orders

30
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

31
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

32
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 appropriately

33
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

34
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 forms
  • Obtain forms at www.med.unc.edu/irb

35
Questions?
  • 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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