Health Information Management

Health Information Management

Posted on Jun 5, 2017 in Health Information Management | 0 comments

Did you know you can request a change to your deficiency notification letter preference?

The following deficiency notification letter preferences are available:

  • Inbasket (default)
  • Fax
  • Email

If you current preference is not meeting your needs, please reach out to your Health Information Manager. Contact information below:

Alisa Stinn, RHIT
Health Information Manager / HIM Leader
Alta Bates Summit Medical Center-Oakland Campus
stinnal@sutterhealth.org
(Office) 510-869-8741
(Fax) 510-869-8856

What’s New With Our Suspension Process?

Posted on May 2, 2017 in Health Information Management | 0 comments

  1. Notification of extended suspension days letter and process was approved at the April MEC meeting.
  2. Effective July 2017, providers that have accumulated 30 or more suspension days or have been on the suspension list for three or more times within a six month period will receive a letter from their respective Department Chair and the Medical Record Committee Chair.
  3. A copy of the letter will be placed in the Credentials Quality File and will be reviewed by the Department Chair at time of re-appointment.

Alisa Stinn, RHIT
Health Information Manager / HIM Leader
Alta Bates Summit Medical Center-Oakland Campus

New Dictation Cards

Posted on Apr 7, 2017 in Health Information Management | 0 comments

S3 in collaboration with the HIM Leadership at each affiliate has been doing a work type consolidation in the Transcription system to deactivate work types that have not been used in years, to streamline the system and to standardize the work types across all the affiliates.

As a result, Alta Bates Summit has new dictation cards with a few new work types added including EEG, Behavioral Health Consult and Outpatient Consultation.

The cards were also updated to include after hour support information.

New dictation cards will be available at the HIM and Medical Staff Departments start 4/1/2017.

http://newsmedstaffsummit.altabatessummit.org/files/2017/04/ABSMC-101_Proof-Transcription-Card-3-2017.pdf

From Alisa Stinn, RHIT

Tips for your Preoperative H&P

Posted on Mar 7, 2017 in Health Information Management | 0 comments

For those performing surgeries and procedures, please review the following regarding your H&P’s.  One of the many important points to remember is that if your patient is receiving anesthesia other than local anesthesia, an interval H&P is needed after your patient is “checked-in / admitted” for a procedure whenever the H&P is done within 30 days.  This includes H&Ps that may have been done in your office only hours before.

1. H&P completed after check in / admission, no interval update is required.

2. Inpatient and Outpatient procedures: H&P within 30 days:

– H&P update / Interval note must be completed and documented within 24 hours after admission but always prior to surgery for an operation or procedure requiring anesthesia, other than local.
– H&Ps done within 30 days of admission are acceptable if the Physician documents an “H&P interval note”  that includes the fact that the patient was re-examined and the full HP was reviewed, no changes or changes documented.
– Update must be signed, dated and timed.
– It is recommended that the H&P update / Interval note be documented directly into EPIC.  If entering directly into EPIC the following navigators tools are available for your use.
– Access the Preop tab within the Periop navigator.  There is an activity that says “H&P interval notes”, click on the button that says “add interval”.
– A template is available called “General H&P update note”.  Template can be reached through your note navigator.

3. All H&P’s must:

– Include date, time and signature.
– If using your office H&P do not use white out to change dates and do not obliterate by writing over the old date of H&P.
– Do not use signature stamps.
– Documentation in the body of the H&P must coincide with the H&P dates.
– H&P performed more than 30 days prior to admission does not comply with timeliness requirements and a new H&P must be performed.

Entering H&P directly in EPIC?

– Ensure H&P is entered on the correct surgical encounter.

From Alisa Stinn, RHIT

Verbal & Telephone Order Compliance

Posted on Jan 3, 2017 in Health Information Management | 0 comments

All verbal and telephone orders are required to be signed within 48 hours. This includes the following order status:

Completed

  1. Discontinued
  2. Canceled
  3. Dispended
  4. Sent
  5. Verified

The majority of  ABSMC non-compliant orders fall into categories other than “completed.”

From Alisa Stinn, RHIT
Client Location Lead / Health Information Manager
Alta Bates Summit Medical Center-Oakland Campus
stinnal@sutterhealth.org
(Office) 510-869-8741
(Cell) 510-381-5181
(Fax) 510-869-8856

Hospital Inpatient Admission Order and Certification

Posted on Dec 1, 2016 in Health Information Management | 0 comments

Did you know that CMS requires admission orders to be signed by an MD prior to a patient’s discharge in order to be billed for that encounter?

As a condition of payment for hospital inpatient services under Medicare Part A, section 1814(a) of the Social Security Act requires physician certification of the medical necessity that such services be provided on an inpatient basis. The order to admit as an inpatient (“practitioner order”) is a critical element of the physician certification, and is therefore also required for hospital inpatient coverage and payment under Part A. The physician certification, which includes the practitioner order, is considered along with other documentation in the medical record as evidence that hospital inpatient service(s) were reasonable and necessary. When a physician signs the certification, they are certifying that inpatient hospital services were reasonable and necessary.

The following guidance applies to all inpatient hospital and critical access hospital (CAH) services unless otherwise specified. For the remainder of this guidance, when we refer to hospitals, we are also referring to CAHs. The complete requirements for the physician certification are found in 42 CFR Part 424 subpart B and 42 CFR 412.3. An electronic version of the CFR is available online at:

https://www.cms.gov/MEdicare/Medicare-fee-for-service-payment/acuteinpatientPPS/downloads/IP-Certification-and-order-01-30-14.pdf

Alisa Stinn, RHIT
Client Location Lead / Health Information Manager
Alta Bates Summit Medical Center-Oakland Campus
stinnal@sutterhealth.org
(Office) 510-869-8741
(Cell) 510-381-5181
(Fax)  510-869-8856