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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

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
slide3
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
slide6

OPERATIVE

REPORT

Dictated within 24 hours after the procedure

slide7

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

slide11

MIS Pathway Discharge Summary

State who is responsible for dictating the discharge summary

slide12

IN ORDER TO USE MIS PATHWAY,

MUST BE ENTERED ON SAME DAY OF DISCHARGE

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

slide23

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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