HIM Department

Posted on Oct 10, 2017 in Health Information Management | 0 comments

**Your assistance is needed-timely chart completion**

  • As you know the Suspension process has been on hold since early July. As a result, our internal delinquent record count has risen.  While suspension processing continues to be on hold, we ask that you sign your chart deficiencies and your delinquent medical records timely. Our goal is to stay as current as possible to minimize the impact when Suspension is re-implemented.
  • Please address ALL charts in your chart completion folder, including any outstanding queries.

** History and Physical Compliance**

  • Is your patient having surgery? H&P completed after check in / admission but prior to surgery, no interval update is required.
  1. 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&P’s 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 navigators tools are available for your use.
  1. 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’s performed more than 30 days prior to admission do not comply with timeliness requirements and a new H&P must be performed.
  1. Entering H&P directly in EPIC?
  • Ensure H&P is entered on the correct surgical encounter.

If you have any questions, please feel free to reach out to me for assistance.

Thank you,
Alisa Stinn, RHIT
Health Information Manager / HIM Leader
Alta Bates Summit Medical Center-Oakland Campus
(Office) 510-869-8741
(Cell) 510-381-5181
(Fax)  510-869-8856

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