documentation, chart completion, and chart management joni perry, rhia, director medical information...

DOCUMENTATION, CHART DOCUMENTATION, CHART COMPLETION, AND CHART COMPLETION, AND CHART

MANAGEMENTMANAGEMENTJONI PERRY, RHIA, DIRECTORJONI PERRY, RHIA, DIRECTOR

MEDICAL INFORMATION MEDICAL INFORMATION MANAGEMENTMANAGEMENT

Documentation RequirementsDocumentation Requirementsat Time of Admissionat Time of Admission

H&Ps are to be dictated within 24 hours H&Ps are to be dictated within 24 hours and signed by the attending physicianand signed by the attending physician

BriefBrief handwritten admit notes are entered in handwritten admit notes are entered in the paper record or directly keyed into the the paper record or directly keyed into the progress notes on the WebCISprogress notes on the WebCIS

Documentation RequirementsDocumentation Requirementsin the Peri-operative Periodin the Peri-operative Period

Operative Reports are to be dictated Operative Reports are to be dictated immediately after surgery and electronically immediately after surgery and electronically signed by the attending physiciansigned by the attending physician

Brief Operative Notes are to be completed Brief Operative Notes are to be completed and filed in the medical record immediately and filed in the medical record immediately after surgeryafter surgery

Documentation RequirementsDocumentation Requirementsat time of dischargeat time of discharge

Final Discharge Notes and Orders are to be completed Final Discharge Notes and Orders are to be completed at discharge on all patients placed in a bed and at discharge on all patients placed in a bed and admissions less than 48 hours are to be signed by the admissions less than 48 hours are to be signed by the attending physicianattending physician

Discharge Summaries are to be dictated at discharge Discharge Summaries are to be dictated at discharge for:for:– admissions > 48 hoursadmissions > 48 hours– deaths (include date and time of death)deaths (include date and time of death)– AMA’s (against medical advice)AMA’s (against medical advice)

Discharge Summaries are to be electronically signed by Discharge Summaries are to be electronically signed by the attending physicianthe attending physician

Documentation RequirementsDocumentation Requirements

Verbal Orders are to be signed and dated ASAPVerbal Orders are to be signed and dated ASAP No white out or obliterations are made in the No white out or obliterations are made in the

record. record. To make corrections, draw one line, write To make corrections, draw one line, write “error”, sign and date correction“error”, sign and date correction

All entries in the medical record must be All entries in the medical record must be authenticated with name, title, ID number and authenticated with name, title, ID number and dated and MUST BE LEGIBLE!dated and MUST BE LEGIBLE!

Must sign and enter corrections/changes to Must sign and enter corrections/changes to dictated documents electronicallydictated documents electronically

Documentation Requirements Documentation Requirements

All inpatient discharges must have all All inpatient discharges must have all documentation requirements completed documentation requirements completed within 28 days post dischargewithin 28 days post discharge

Clinic notes must be dictated within 24 Clinic notes must be dictated within 24 hours and electronically edited and signed hours and electronically edited and signed within 5 days of servicewithin 5 days of service

Incomplete Documentation Incomplete Documentation NotificationsNotifications


Day of weekDay of week Topic Topic AddresseesAddressees

FridaysFridays List of List of incomplete incomplete recordsrecords

ProvidersProviders

ThursdaysThursdays Executive Executive Summary Summary and Chart and Chart Status Status ReportReport

Chairs and Chairs and Residency Residency Training Training DirectorsDirectors


Day of weekDay of week Topic Topic AddresseesAddressees

Mondays-Mondays-FridaysFridays

List of List of Undictated Undictated Operative Operative Reports Reports (email)(email)

ChairsChairs

Residency Residency DirectorsDirectors

TuesdaysTuesdays Undictated Undictated Discharge Discharge Summary Summary ReportsReports

Chairs Chairs Residency Residency DirectorsDirectors

Administrative Suspension Administrative Suspension ProcessProcess

Notification of Pending Notification of Pending Suspension provided on Suspension provided on Mondays to: Mondays to: –ProviderProvider

–ChairChair

–Residency Training DiretorResidency Training Diretor

Administrative Suspension Administrative Suspension CriteriaCriteria

At least one 28-day incomplete record and At least one 28-day incomplete record and available to the provider for at least a weekavailable to the provider for at least a week

Provider has not attempted to complete Provider has not attempted to complete it/them in the past weekit/them in the past week

Provider/Department has not notified the Provider/Department has not notified the MIM Department of extenuating MIM Department of extenuating circumstances (sick, vacation, etc.)circumstances (sick, vacation, etc.)


Day 1 (Fridays) – MIMD Day 1 (Fridays) – MIMD Determines Eligibility and Determines Eligibility and Provider contacted by MIMD, Provider contacted by MIMD, House staff office, or Clinical House staff office, or Clinical DepartmentDepartment


Day 4 (Mondays) - Notification Day 4 (Mondays) - Notification of Pending Suspensions to:of Pending Suspensions to:ProviderProviderChairChairResidency Training DirectorResidency Training DirectorOthers Others


Day 6 (Wednesdays) – Notifications of Final Day 6 (Wednesdays) – Notifications of Final Suspensions to:Suspensions to: ProviderProvider Clinical Department ChairClinical Department Chair Residency Training DirectorResidency Training Director OthersOthers

Signed by Chief of Staff and Hospitals’ Chief Signed by Chief of Staff and Hospitals’ Chief Operating OfficerOperating Officer

Until Suspension Records are Until Suspension Records are Completed…..Completed…..

Cannot admit new patients, schedule new Cannot admit new patients, schedule new surgical procedures, provide care to patients surgical procedures, provide care to patients in ED nor schedule new clinic appointmentsin ED nor schedule new clinic appointments

Cannot provide care to patients in the E.D.Cannot provide care to patients in the E.D. House Staff Physicians are removed from House Staff Physicians are removed from

all clinical activities and placed on annual all clinical activities and placed on annual leaveleave

Other penalties as imposed by the Other penalties as imposed by the individual clinical departments and servicesindividual clinical departments and services

On-going Activities Related to On-going Activities Related to Chart Completion/suspensionChart Completion/suspension

Weekly notification letters are mailed each Friday Weekly notification letters are mailed each Friday to all providers with one or more incomplete to all providers with one or more incomplete record. Notification letters include all incomplete record. Notification letters include all incomplete records with an asterisk (*) indicating those charts records with an asterisk (*) indicating those charts 28 days and older28 days and older

The MIM Committee Chairman submits, upon The MIM Committee Chairman submits, upon request and during the reappointment process, any request and during the reappointment process, any provider who has had 1 or more pending/final provider who has had 1 or more pending/final suspensions within a 12-month period. This suspensions within a 12-month period. This information is utilized by the Department Chairs information is utilized by the Department Chairs for consideration in credentialing reviewsfor consideration in credentialing reviews

How To Avoid SuspensionHow To Avoid Suspension

Call 6-4425 for advance pulling of Call 6-4425 for advance pulling of chartscharts

Come by the Workroom and complete Come by the Workroom and complete ESA’s at least weeklyESA’s at least weekly

Notify the Workroom when away on Notify the Workroom when away on vacation or extended leave and vacation or extended leave and complete all records just prior to complete all records just prior to leavingleaving

How To Avoid SuspensionHow To Avoid Suspension

Complete inpatient documentation Complete inpatient documentation on the unit at the time or before the on the unit at the time or before the patient is dischargedpatient is discharged

Enforce documentation Enforce documentation requirements of the residents and requirements of the residents and monitor their performancemonitor their performance

Transcription ServicesTranscription Services

Inpatient:Inpatient:– Dial 6-1111 on any touch tone phoneDial 6-1111 on any touch tone phone– Enter Enter

physician ID code physician ID code withoutwithout check check digitdigit

one-digit work typeone-digit work typePatient’s medical record number Patient’s medical record number

withoutwithout the check digit the check digit


Inpatient Work Types:Inpatient Work Types: 1= DC Summary1= DC Summary 2= Operative Report2= Operative Report 4=Stat Report (transfers only)4=Stat Report (transfers only) 5=History & Physicals5=History & Physicals 3=Normal OB Delivery Notes3=Normal OB Delivery Notes


Inpatient Auto faxingInpatient Auto faxing

– Dictate Referring/Primary Care Dictate Referring/Primary Care provider informationprovider information

– Faxed from MIM Dept. Faxed from MIM Dept. Computerized fax system Computerized fax system Immediately following transcription Immediately following transcription or mailed if fax number not availableor mailed if fax number not available


Outpatient:Outpatient:– Must dictate all clinic notes Must dictate all clinic notes

through one of the approved through one of the approved systems: systems: UNCHCS contracted serviceUNCHCS contracted serviceInternally utilizing Chartscript Internally utilizing Chartscript

within the Departmentwithin the Department


Utilize the approved template for new Utilize the approved template for new patient visits and established patient patient visits and established patient visitsvisits

Documents are transcribed within 24 Documents are transcribed within 24 hours and auto faxed to referring hours and auto faxed to referring physician upon editing and electronic physician upon editing and electronic signature on the Clinical Information signature on the Clinical Information System (CIS)System (CIS)

Paper Chart OrganizationPaper Chart Organization

Inpatient Universal Chart Order – Inpatient Universal Chart Order – same order post discharge as on the same order post discharge as on the unitunit–Dividers list the order of the Dividers list the order of the

documents to be filed documents to be filed –Must be kept in that order on the Must be kept in that order on the

unitunit

Chart OrganizationChart Organization

Documents on Clinical Information System Documents on Clinical Information System (CIS) are not printed and filed in the paper chart: (CIS) are not printed and filed in the paper chart:

History & History & PhysicalsPhysicals

Laboratory Laboratory ReportsReports

Respiratory Respiratory Therapy Therapy ReportsReports

Discharge Discharge SummariesSummaries

Radiology Radiology ReportsReports

Direct Entry Direct Entry Progress Progress NotesNotes

Operative Operative ReportsReports

Pathology Pathology ReportsReports

Clinic NotesClinic Notes


Circulating Record System Circulating Record System

– Multiple volumes are streamlined into Multiple volumes are streamlined into one volume that has the clinical one volume that has the clinical documents (key) in it, which circulatesdocuments (key) in it, which circulates

– Other volumes that store the “bulk” (non-Other volumes that store the “bulk” (non-key) which do not circulatekey) which do not circulate


Key Documents – Key Documents –

– ED RecordED Record

– ConsultationsConsultations

– Anesthesia RecordAnesthesia Record

– EKG Reports (all others are on CIS)EKG Reports (all others are on CIS)

– Outpatient documentsOutpatient documents


Non-Key Documents Non-Key Documents – Flow SheetsFlow Sheets– Medication Administration RecordsMedication Administration Records– Handwritten Physician Progress Handwritten Physician Progress

NotesNotes– Nurses’ NotesNurses’ Notes– Medical OrdersMedical Orders

Chart Organization – Circulating Chart Organization – Circulating Record SystemRecord System

Records of Discharged Patients:Records of Discharged Patients:– Original documents are filed in temporary Original documents are filed in temporary

workroom folders for completionworkroom folders for completion– Copies of incomplete admissions where the Copies of incomplete admissions where the

documents are not on CIS are available documents are not on CIS are available upon request by calling 6-4425upon request by calling 6-4425

– Original documents are filed in the Original documents are filed in the permanent circulating volume following permanent circulating volume following chart completionchart completion

Accessibility and Management of Accessibility and Management of Charts and Patient InformationCharts and Patient Information

Access to Patient Information in paper Access to Patient Information in paper or CIS must be made on a “need to or CIS must be made on a “need to know” basis for performing job dutiesknow” basis for performing job duties

Charts must not be removed from Charts must not be removed from clinic or unit or hospital propertyclinic or unit or hospital property

Accessibility and Management of Accessibility and Management of Charts and Patient InformationCharts and Patient Information

Charts must be returned from clinic Charts must be returned from clinic within 24 hours or from the unit the within 24 hours or from the unit the day post dischargeday post discharge

Return charts to clinic front desk when Return charts to clinic front desk when patients have multiple appointments on patients have multiple appointments on the same day to be transferred the same day to be transferred appropriatelyappropriately

Release of Medical Information Release of Medical Information and Researchand Research

Requests for patient information Requests for patient information received from outside requesters such as received from outside requesters such as insurance companies, attorneys, patients, insurance companies, attorneys, patients, etc. must be handled by the Release of etc. must be handled by the Release of Information area of the MIM Dept.Information area of the MIM Dept.

Charts requested for the purposes of Charts requested for the purposes of quality assessments and research projects quality assessments and research projects are not to be removed from the Research are not to be removed from the Research are of the MIMare of the MIM

Release of Medical Information Release of Medical Information and Researchand Research

Requests for computerized patient data, Requests for computerized patient data, paper charts, and access to patient paper charts, and access to patient information on the CIS for the information on the CIS for the purposes of research require purposes of research require appropriate completion of specific appropriate completion of specific formsforms

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

Questions?Questions?

Administrative and General – 6-1225Administrative and General – 6-1225 Physicians’ Workroom – 6-4425Physicians’ Workroom – 6-4425 Chart Management and Retrieval – 6-2312 Chart Management and Retrieval – 6-2312

(24 hours a day/7 days per week)(24 hours a day/7 days per week) Inpatient Transcription – 6-4797Inpatient Transcription – 6-4797 Outpatient Transcription – 6-2525Outpatient Transcription – 6-2525 Release of Medical Information – 6-2336Release of Medical Information – 6-2336 Research – 6-5655Research – 6-5655

documentation, chart completion, and chart management joni perry, rhia, director medical information...

Documents

documentation requirements

attending physician

medical record

progress notes

attending physician

surgery slide

surgery brief operative

webcis slide