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Medical Records

Medical Records. House Staff Orientation Location: Basement of Rock Financial Counseling & Medical Records. Hours of operation 7 days a week 2 shifts – 7:30 a.m. through 11 p.m. Main phone number – 2-2044 215-707-2044. Key Interaction with the Medical Record Department.

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Medical Records

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  1. Medical Records House Staff Orientation Location: Basement of Rock Financial Counseling & Medical Records • Hours of operation • 7 days a week • 2 shifts – 7:30 a.m. through 11 p.m. • Main phone number – 2-2044 • 215-707-2044

  2. Key Interaction with the Medical Record Department • Record Access – Imaged medical record, Alpha Imaging • Record Completion – on-line • Discharge Summary Dictation • Operative Report Dictation • Death Certificates/Gift of Life/Autopsy consent • Documentation

  3. DICTATION • Personal dictation # to access the system • Complete computer training, receive dictation system access How to Dictate Within hospital, dial 5555 Outside hospital, dial 1-877-292-5018 Follow prompts Enter your dictation # Identify the work type1 Operative Report – TUH2 Discharge Summary –TUH Use the blue dictation card as a guide

  4. Dictation TIPS • Start with: • patient name (spell it) • medical record # • admit & discharge date • include Attending by name • At end of dictation a job # for dictation is provided – enter it into Alpha at the prompt

  5. OPERATIVE REPORTS Required for EVERY operative procedure performed in the Operating Room Inpatient and outpatient 1. Immediate Post OPform to be filled out immediately following the procedure 2. Full Dictation also required through dictation system • Dictate Immediately after procedure • Complete OP report within 24 hoursof procedure

  6. OPERATIVE REPORT Dictated within 24 hours after the procedure

  7. IMMEDIATE POST OP NOTE Complete immediately following procedures performed in O.R. before patient moves to next level of care Serves as a communication tool while OP report is being transcribed Write DATE and TIME on everything Findings: Be Specific DO NOT write “See….”

  8. DISCHARGE SUMMARIES • Required on ALL inpatient admissions • LOS < 4 days use the MIS pathway • Complete all items • “Pending”-not acceptable • LOS > 5 days requires a dictated Discharge Summary • Refer to BLUE dictation cards

  9. Dictated DC Summary - Good Key Components Patient’s name (Spell) Medical Record / Account Number Admission/Discharge, Expiration Date Attending Physician History of Present Illness Hospital Course by Problem Disposition & Discharge Instructions Dictating Physician (Spell) Copies: Names (Spell) and Addresses

  10. Dictated DC Summary - Bad Key Components Patient’s name (Spell) Medical Record Number Admission/Discharge, Expiration Date Attending Physician History of Present Illness Hospital Course by Problem Disposition & Discharge Instructions Dictating Physician (Spell) Copies: Names (Spell) and Addresses

  11. MIS Pathway Discharge Summary State who is responsible for dictating the discharge summary

  12. IN ORDER TO USE MIS PATHWAY, MUST BE ENTERED ON SAME DAY OF DISCHARGE

  13. MIS DC Summary - Good

  14. MIS DC Summary - Bad

  15. Completion of Death Certificate and related documents overview

  16. Nursing Unit Instruction Packets Located on all nursing units • Death Certificate blank and sample • Gift of Life • Consent to Autopsy Form • Medical Examiner protocol • MIS Pathway must be completed Please note – the decedent cannot be released to the funeral director without the completed paperwork.

  17. MIS PATHWAY State who is dictating the discharge summary Note a Gift of Life entry Note whether or not it is a Medical Examiner case

  18. DEATH CERTIFICATE • Most common errors • Black ink, • NO cross-outs, • NO overwrites, • name only on side, • and cardiac arrest is NOT an acceptable cause of death!

  19. GIFT OF LIFE EVERY DEATH must be called into Gift of Life This is a PA state requirement

  20. CONSENT TO AUTOPSY FORM Most common error – must be signed by the physician on the witness line

  21. Documentation Authentication is date/time/sign/contact phone # Write Legibly Abbreviations list Verbal orders signed within 24 hours in MIS Point of Care Scanning & Coding

  22. POC Coding Worksheet On admission • Code on admission for two purposes • Documentation questions for coding • CORE measure admission identification

  23. Never Use the Following Abbreviations • QD (daily) • QOD (every other day) • U (units) • IU (International units) • MSO4 (Morphine Sulfate) • MGSO4 (Magnesium Sulfate) • MS (Morphine sulphate, mental status, etc) • ARA-A & ARA-C (Cytarabine) • OXY (OXY-IR, Oxycontin, Oxycodone & Oxytocin) • MTX (Methotrexate) • Medication Dosages: • Never Use Terminal Zeros (1.0) • Always Use Leading Zeros (0.5)

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