Health Information Management Update

Posted on Oct 1, 2021 in Uncategorized | 0 comments

The Survey Window is open!

  • Complete and timey documentation
  • Sign you incomplete charts timely
  • Do your Verbal Orders often

Chart Completion:  Courtesy Text Message

  • Medical Record Committee members requested a more direct way to contact physicians.  A courtesy text message was proposed and sent to Medical Executive Committee for review and approval.
  • A courtesy text message was approved.  Physician cell phone numbers will be obtained from the Medical Staff Office.
  • The courtesy text message will replace the courtesy phone call made by HIM. 
  • Physicians will continue to receive other delinquency notifications via their notification preference (email, FAX or EHR inbasket)
  • The new text message was implemented June 2021.
  • When you receive an HIM text message, please complete your delinquent medical records before Thursday at noon.

Verbal Order Compliance:

Providers are required to cosign Verbal/Telephone Orders in fewer than 48 hours.  When a provider fails to do so, the provider is out of compliance and a deficiency is created. Our goal is to increase our compliance to a minimum of 95%.

Handy Tips:

  • Hardwire signing your Verbal/Telephone Orders by signing them when you end your shift.
  • Be sure to Sign all Verbal/Telephone orders including Discontinued and Canceled orders.
  • Work with your group to sign orders for each other.
  • Haiku provides access to your In Basket and you can quickly cosign there.
  • Email Reminders can be set up from your EPIC In Basket.

If you having difficulty reaching or exceeding the 95% goal, please contact your EHR Physician Liaison for assistance!

Surgery Documentation:

  • Please remember to include the EBL and Specimens removed in your IPON and or Operative Reports.  These elements are required.

Alisa Stinn, RHIT, Manager Health Information Department

ABSMC, SEBMF | 350 Hawthorne Ave | Oakland, CA 94609| P: 510.869-8741 | F: 510.869-8856 | M: 510.381-5181