Medical records
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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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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

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


  • Medical records

    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


    Dictation tips

    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


    Operative reports

    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


    Medical records

    OPERATIVE

    REPORT

    Dictated within 24 hours after the procedure


    Medical records

    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….”


    Discharge summaries

    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


    Dictated dc summary good

    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


    Dictated dc summary bad

    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


    Medical records

    MIS Pathway Discharge Summary

    State who is responsible for dictating the discharge summary


    Medical records

    IN ORDER TO USE MIS PATHWAY,

    MUST BE ENTERED ON SAME DAY OF DISCHARGE


    Mis dc summary good

    MIS DC Summary - Good


    Mis dc summary bad

    MIS DC Summary - Bad


    Completion of death certificate

    Completion of Death Certificate

    and related documents overview


    Nursing unit instruction packets

    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.


    Mis pathway

    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


    Death certificate

    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!


    Gift of life

    GIFT OF LIFE

    EVERY DEATH must be called into Gift of Life

    This is a PA state requirement


    Consent to autopsy form

    CONSENT TO AUTOPSY FORM

    Most common error –

    must be signed by

    the physician

    on the

    witness line


    Documentation

    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


    Medical records

    POC Coding Worksheet

    On admission

    • Code on admission for two purposes

    • Documentation questions for coding

    • CORE measure admission identification


    Never use the following abbreviations

    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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