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

2. 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

3. 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

4. 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

5. 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

6. 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

7. Incomplete Documentation Notifications

8. 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

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

10. Administrative Suspension Process

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

12. 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.)

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

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

15. 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

16. 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

17. 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

18. How To Avoid Suspension
Call 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

19. 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

20. Transcription Services
Inpatient:
Dial 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

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

22. 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

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

24. 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)

25. 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

26. 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

27. 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

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

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

30. 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
Original documents are filed in the permanent circulating volume following chart completion

31. 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

32. 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

33. 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

34. 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

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