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 • 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

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 > 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

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

9. Incomplete Documentation Notifications

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 ESA’s 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 • Patient’s medical record number without the check digit

21. Transcription Services • Inpatient Work Types: • 1= DC Summary • 2= Operative Report • 4=Stat Report (transfers only) • 5=History & Physicals • 3=Normal 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:

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