DOCUMENTATION, CHART COMPLETION, AND CHART MANAGEMENT JONI PERRY, RHIA, DIRECTOR MEDICAL INFORMATION MANAGEMENT

Documentation Requirements at Time of Admission H&Ps are to be dictated within 24 hours and signed by the attending physician Brief handwritten admit notes are entered in the paper record or directly keyed into the progress notes on the WebCIS

Documentation Requirements in the Peri-operative Period Operative Reports are to be dictated immediately after surgery and electronically signed by the attending physician Brief Operative Notes are to be completed and filed in the medical record immediately after surgery

Documentation Requirements at time of discharge Final Discharge Notes and Orders are to be completed at discharge on all patients placed in a bed and admissions less than 48 hours are to be signed by the attending physician Discharge Summaries are to be dictated at discharge for: admissions > 48 hours deaths (include date and time of death) AMA’s (against medical advice) Discharge Summaries are to be electronically signed by the attending physician

Documentation Requirements Verbal Orders are to be signed and dated ASAP No white out or obliterations are made in the record. To make corrections, draw one line, write “error”, sign and date correction All entries in the medical record must be authenticated with name, title, ID number and dated and MUST BE LEGIBLE! Must sign and enter corrections/changes to dictated documents electronically

Documentation Requirements All inpatient discharges must have all documentation requirements completed within 28 days post discharge Clinic notes must be dictated within 24 hours and electronically edited and signed within 5 days of service

Incomplete Documentation Notifications

Incomplete Documentation Notifications Day of week Topic Addressees Fridays List of incomplete records Providers Thursdays Executive Summary and Chart Status Report Chairs and Residency Training Directors

Incomplete Documentation Notifications Day of week Topic Addressees Mondays-Fridays List of Undictated Operative Reports (email) Chairs Residency Directors Tuesdays Undictated Discharge Summary Reports Chairs Residency Directors

Administrative Suspension Process

Notification of Pending Suspension provided on Mondays to: Provider Chair Residency Training Diretor

Administrative Suspension Criteria At least one 28-day incomplete record and available to the provider for at least a week Provider has not attempted to complete it/them in the past week Provider/Department has not notified the MIM Department of extenuating circumstances (sick, vacation, etc.)

Administrative Suspension Process Day 1 (Fridays) – MIMD Determines Eligibility and Provider contacted by MIMD, House staff office, or Clinical Department

Administrative Suspension Process Day 4 (Mondays) - Notification of Pending Suspensions to: Provider Chair Residency Training Director Others

Administrative Suspension Process Day 6 (Wednesdays) – Notifications of Final Suspensions to: Provider Clinical Department Chair Residency Training Director Others Signed by Chief of Staff and Hospitals’ Chief Operating Officer

Until Suspension Records are Completed….. Cannot admit new patients, schedule new surgical procedures, provide care to patients in ED nor schedule new clinic appointments Cannot provide care to patients in the E.D. House Staff Physicians are removed from all clinical activities and placed on annual leave Other penalties as imposed by the individual clinical departments and services

On-going Activities Related to Chart Completion/suspension Weekly notification letters are mailed each Friday to all providers with one or more incomplete record. Notification letters include all incomplete records with an asterisk (*) indicating those charts 28 days and older The MIM Committee Chairman submits, upon request and during the reappointment process, any provider who has had 1 or more pending/final suspensions within a 12-month period. This information is utilized by the Department Chairs for consideration in credentialing reviews

How To Avoid Suspension Call 6-4425 for advance pulling of charts Come by the Workroom and complete ESA’s at least weekly Notify the Workroom when away on vacation or extended leave and complete all records just prior to leaving

How To Avoid Suspension Complete inpatient documentation on the unit at the time or before the patient is discharged Enforce documentation requirements of the residents and monitor their performance

Transcription Services Inpatient: Dial 6-1111 on any touch tone phone Enter physician ID code without check digit one-digit work type Patient’s medical record number without the check digit

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

Transcription Services Inpatient Auto faxing Dictate Referring/Primary Care provider information Faxed from MIM Dept. Computerized fax system Immediately following transcription or mailed if fax number not available

Transcription Services Outpatient: Must dictate all clinic notes through one of the approved systems: UNCHCS contracted service Internally utilizing Chartscript within the Department

Transcription Services Utilize the approved template for new patient visits and established patient visits Documents are transcribed within 24 hours and auto faxed to referring physician upon editing and electronic signature on the Clinical Information System (CIS)

Paper Chart Organization Inpatient Universal Chart Order – same order post discharge as on the unit Dividers list the order of the documents to be filed Must be kept in that order on the unit

Chart Organization Documents on Clinical Information System (CIS) are not printed and filed in the paper chart: History & Physicals Laboratory Reports Respiratory Therapy Reports Discharge Summaries Radiology Reports Direct Entry Progress Notes Operative Reports Pathology Reports Clinic Notes

Chart Organization Circulating Record System Multiple volumes are streamlined into one volume that has the clinical documents (key) in it, which circulates Other volumes that store the “bulk” (non-key) which do not circulate

Chart Organization Key Documents – ED Record Consultations Anesthesia Record EKG Reports (all others are on CIS) Outpatient documents

Chart Organization Non-Key Documents Flow Sheets Medication Administration Records Handwritten Physician Progress Notes Nurses’ Notes Medical Orders

Chart Organization – Circulating Record System Records of Discharged Patients: Original documents are filed in temporary workroom folders for completion Copies of incomplete admissions where the documents are not on CIS are available upon request by calling 6-4425 Original documents are filed in the permanent circulating volume following chart completion

Accessibility and Management of Charts and Patient Information Access to Patient Information in paper or CIS must be made on a “need to know” basis for performing job duties Charts must not be removed from clinic or unit or hospital property

Accessibility and Management of Charts and Patient Information Charts must be returned from clinic within 24 hours or from the unit the day post discharge Return charts to clinic front desk when patients have multiple appointments on the same day to be transferred appropriately

Release of Medical Information and Research Requests for patient information received from outside requesters such as insurance companies, attorneys, patients, etc. must be handled by the Release of Information area of the MIM Dept. Charts requested for the purposes of quality assessments and research projects are not to be removed from the Research are of the MIM

Release of Medical Information and Research Requests for computerized patient data, paper charts, and access to patient information on the CIS for the purposes of research require appropriate completion of specific forms Obtain forms at www.med.unc.edu/irb

Questions? Administrative and General – 6-1225 Physicians’ Workroom – 6-4425 Chart Management and Retrieval – 6-2312 (24 hours a day/7 days per week) Inpatient Transcription – 6-4797 Outpatient Transcription – 6-2525 Release of Medical Information – 6-2336 Research – 6-5655