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Health Information Management Department

Health Information Management Department. Hours of operation 7 days a week 2 shifts – 7:30 a.m. through 11 p.m. House Staff Orientation Location: Basement of Rock Pavilion Southeast corner Broad and Ontario Streets Health Information Management Department Room A-215.

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Health Information Management Department

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  1. Health Information Management Department Hours of operation 7 days a week 2 shifts – 7:30 a.m. through 11 p.m. House Staff Orientation Location: Basement of Rock Pavilion Southeast corner Broad and Ontario Streets Health Information Management Department Room A-215 Main phone number – 2-3755 215-707-3755

  2. Resident’s Key Interaction with the HIM Department • System Access: Alpha Imaging • Chart Deficiency completion • Suspension/Reinstatement • Documentation • Dictation • Death Certificates • Autopsy consents • Gift of Life

  3. Resident’s Key Interaction with the HIM Department • System Access: Alpha Imaging • Chart Deficiency completion • Complete dictations within xx days • Suspension/Reinstatement • 1 chart >30 days post discharge • 10+ charts >7 days post discharge

  4. Resident’s Key Interaction with the HIM Department • Documentation • Immediate Post Op Note • Complete before level of care changes • Dictation • Operative Reports • Complete within 24 hours • Discharge Summaries • Required on all admissions • Completed within 30 days of discharge

  5. IMMEDIATEPOST OP NOTE • ALWAYS • Complete the Immediate Post Op Note • Dictation is required on EVERY operating room procedure • Consult blue dictation card for reference if needed

  6. Dictated DC Summary - Good

  7. Resident’s Key Interaction with the HIM Department • Documentation • Death Certificates • Autopsy consents • Gift of Life

  8. Completion of Death Certificates Located on all nursing units • Death Certificate blank and sample form • Gift of Life • Consent to Autopsy Form • Medical Examiner protocol • MIS Pathway must be completed Please note The decedent’s remains cannot be released to the funeral director without the completed paperwork.

  9. DEATH CERTIFICATE • Use only Black ink • NO cross-outs • NO overwrites • name only on side • Abbreviations may NOT be used • and cardiac arrest without etiology noted is NOT an acceptable cause of death!

  10. CONSENT TO AUTOPSY FORM Most common error: Form must be signed by the physician on the witness line And Write “NONE” if there are no restrictions

  11. Documentation Authentication: sign/date/time/contact phone # Write Legibly Abbreviations list Verbal orders signed within 24 hours in MIS

  12. Never Use the Following Abbreviations Inwritefield.com

  13. Health Information Management Department 2-3755

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