HIM Reminders

Posted on May 2, 2018 in Health Information Management | 0 comments

Out of Office Notice:

Please be reminded to notify HIM when you leave on vacation or going off service for extended period of time.  Before leaving, please complete and sign everything in your in-basket.  HIM will place you out of office which will help ensure your deficiencies do not continue to age and to ensure you will not be placed on suspension in error.

H&P Update:

Question: Is it appropriate to refer to the H&P in Care Everywhere in my H&P update note for surgery such as example below?

Answer: NO, this workflow is unacceptable for several reasons according to Dr. Bill Isenberg, (VP, Patient Safety, Office of Patient Experience) Sutter Attorney, and Health Information Management Leadership.

We are all in agreement that providers should not refer to Care Everywhere in lieu of adding an H&P to the encounter it is needed in. This workflow is unacceptable for several reasons including:

  • It needs to be on the record prior to the patient having surgery.
  • Not easy to find it in Care Everywhere. There were Care Everywhere records from several institutions so you had to know which one to click on. The date on the institutions was not 1/30. You had to click on the links and then hunt for the 1/30 note, which was labeled as a progress note, not an H&P.
  • Even if Nursing did find it, asking them to find it, print it and scan it is asking too much.
  • Care Everywhere documentation does not become part of our legal record for ROI.
  • Care Everywhere documentation does not pull into CAC software for coding.
  • Care Everywhere documentation does not clear an H&P deficiency automatically.

Alisa Stinn, RHIT
Health Information Manager / HIM Lead
Sutter Health
Alta Bates Summit Medical Center
Summit-Ashby-CCC Herrick
510-869-8741 | Direct
510-869-8856 | Fax
510-381-5181 | Mobile
stinnal@sutterhealth.org

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