Health Information Management

EPIC Corner

Posted on Feb 1, 2021 in Health Information Management | 0 comments

2021 Medical Staff Reminders for Medical Records

Posted on Jan 4, 2021 in Health Information Management | 0 comments

Health Information Management Update: Be a shining star…Sign your Verbal Orders within 48 hours to help us reach 95% compliance.

Posted on Dec 2, 2020 in Announcements, Health Information Management | 0 comments

What can you and your team do?

  1. Reach out to your Department Chair or HIM Manager to ask for your personal stats on VO compliance.
  2. Hardwire the process.  It is recommended VO be signed every day.  Ensure your orders are covered if going off service or on vacation.  Remember to notify HIM if going on vacation during holiday’s so that we can place your deficiencies on hold.
  3. Start a competition with other providers within your department.  Who has the best compliance?
  4. Post the compliance report monthly when sent to Department Chairs.
  5. We have been working to improve compliance for years.  It is vital that we continue to improve and then sustain.

Health Information Professionals Week Oct 11-17th

Posted on Nov 3, 2020 in Health Information Management | 0 comments

Operative Report / Immediate Post Op Note Reminder

Posted on Oct 1, 2020 in Health Information Management | 0 comments

Operative Report  / Immediate Post Op Note Reminder

JC Standard RC 02.01.03 EP 5,7: Operative and High Risk Procedure Reports – Timeframe of Dictation or Written In what timeframe must an operative or other high-risk procedure report be dictated and placed in the medical record? The report must be written or dictated immediately after an operative or other high risk procedure.  If the operative or procedural report is not placed in the medical record immediately following the procedure, then a progress note must be immediately entered after the procedure to provide pertinent information to the next provider of care. ‘Immediately after surgery or procedure’ is defined as “upon completion of procedure, before the patient is transferred to the next level of care”. This is to ensure that pertinent information is available to the next caregiver. If the practitioner performing the operation or high-risk procedure accompanies the patient from the operating room to the next unit or area of care, the report can be written or dictated in the new unit or area of care. If the progress note option is used (see RC.02.01.03 EP 7), it must contain, at a minimum, comparable operative/procedural report information. The minimum required elements include; the name of the primary surgeon and assistants procedures performed and description of each procedure findings any estimated blood loss, any specimens removed, and the post-operative diagnosis.

  • ABSMC compliance is measured based on the Joint Commission standard above.
  • Please ensure you are documenting all content requirements in both Operative and IPON.   This also applies if you dictate your operative report.
  • On audit we consistently note several dictated operative reports missing specimens removed and or EBL.  

Alisa Stinn, RHIT
Health Information Manager   
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

VERBAL ORDER COMPLIANCE REMINDERS

Posted on Oct 1, 2020 in Health Information Management | 0 comments

Let’s end the year strong.   Our goal is to reach 90% with a stretch goal of 95%,   Please ensure you do everything you can to help us reach this goal.   As a reminder, surveyors may be arriving, please ensure your orders are signed within 48 hours.

VERBAL ORDER COMPLIANCE REMINDERS

  1. Please remember to sign your Verbal/Telephone Orders. Our Medical Staff Rules and Regulations state that Verbal and Telephone Orders must be signed within 48 hours.
  2. Hardwire signing your Verbal/Telephone Orders. Make signing deficiencies the first and last thing you do daily.
  3. Sign ALL Verbal/Telephone orders including Discontinued and Canceled orders.
  4. Work with your group to sign orders for each other. Inform your team when going off service and ask that your orders be signed.  Patty Fitzgibbons at Summit or Shala Thomas at Ashby will work with you and your group to make it easy to sign each other’s verbal orders.
  5. Set up a daily email reminder to your preferred email.

Thank you in advance for working on this very important compliance measure.

Alisa Stinn, RHIT
Health Information Manager   
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