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

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

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

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

IMMEDIATE POST 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 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 Detailed & Specific DO NOT write “See…. Dictation,Note, Op Report, Findings”

Dictated DC Summary - Good

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

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.

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!

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 One you sign off and witness this form is complete: Note: if the family is allowing the eyes to be donated you would then and only then complete the bottom portion of the form.

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

Never Use the Following Abbreviations Temple University Hospital Do Not Use Abbreviations List Do NOT use this abbreviation: Instead WRITE this: ARA-A Vidarabine ARA-C Cytarabine IU International Unit MGS04 Magnesium Sulfate MS Mental Status, Multiple Sclerosis, Morphine Sulfate, Musculoskeletal MS04 Morphine Sulfate MTX Methotrexate OXY Oxycodone, Oxycontin, Oxytocin QD Every Day, Once Daily QOD Every Other Day U Unit(s) 1.0 mg - Trailing Zero 1 gm .5 ml - Naked Decimal Point 0.5 ml Inwritefield.com

Health Information Management Department 2-3755