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 –

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

DICTATION Personal dictation # to access the system Complete computer training, receive dictation system access How to Dictate Within hospital, dial 5555 Outside hospital, dial Follow prompts Enter your dictation # Identify the work type 1 Operative Report – TUH 2 Discharge Summary –TUH Use the blue dictation card as a guide

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

Required for EVERY operative procedure performed in the Operating Room Inpatient and outpatient 1. Immediate Post OP form 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 hours of procedure

Dictated within 24 hours after the procedure

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….”

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

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

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

MIS Pathway Discharge Summary State who is responsible for dictating the discharge summary

IN ORDER TO USE MIS PATHWAY, MUST BE ENTERED ON SAME DAY OF DISCHARGE

and related documents overview

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.

State who is dictating the discharge summary Note a Gift of Life entry Note whether or not it is a Medical Examiner case

 Most common errors  Black ink,  NO cross-outs,  NO overwrites,  name only on side,  and cardiac arrest is NOT an acceptable cause of death!

EVERY DEATH must be called into Gift of Life This is a PA state requirement

Most common error – must be signed by the physician on the witness line

Authentication is date/time/sign/contact phone # Write Legibly Abbreviations list Verbal orders signed within 24 hours in MIS Point of Care Scanning & Coding

POC Coding Worksheet On admission Code on admission for two purposes 1.Documentation questions for coding 2.CORE measure admission identification

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)