1. 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. 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. 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”

7. Dictated DC Summary - Good

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

9. 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.

10. 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!

11. 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.

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

13. 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

14. Health Information Management Department 2-3755