Health Information Management

Be Survey Ready

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

Be survey ready…Make Verbal/Telephone Orders a high priority!

Continue to focus on your department and individual compliance to ensure all VO/TO orders are signed within 48 hours.

Summit Transcription Reminders when dictating:

To help facilitate the transcription getting to the patient chart timely, please follow the instructions below consistently.

  1. Enter your facility code: 77 for Summit
  2. Enter your dictation speaker code
  3. Enter your work type
  4. Enter the patient’s MRN
  5. Press 2 to begin dictating
  6. Begin the dictation with
  • Your name
  • Patient name and spelling
  • Patient DOB
  • Patient MRN
  • Work type
  • Any CC’s. Full provider name
  1. Please only STAT the dictated report if needed for urgent patient care

Immediate Post Op Progress Note Compliance:

Our compliance has dropped for Immediate Post Op Progress Notes completion.  We are currently at 84% (Goal = 95% completion of post-op note before patient’s transfer to next level of care)

  • If Operative report is not completed immediately, an Immediate Post OP Progress note is required to be completed and signed in the patient chart before the patient is transferred to the next level of care.

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

 

Quick Tips for Verbal and Telephone Orders

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

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.

Right now, we are well below the 90% mark and at risk for citation by regulatory agencies. Please do your part and sign your orders ASAP.

Below are some handy tips:

  1. Hardwire signing your Verbal/Telephone Orders. Make signing deficiencies the first and last thing you do daily.
  2. Sign ALL Verbal/Telephone orders including Discontinued and Canceled orders.
  3. 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 will work with you and your group to make it easy to sign each other’s verbal orders.
  4. Inform Health Information Management when going on vacation so deficiencies can be placed on hold while you are out.

In order to place a hold on any potential medical record deficiencies, you have 3 options:

  1. Call the local HIM/Medical Records Department, Chart Completion Team at Summit: 510-869-6545, option 2 (Summit Campus only).
  2. Call or email the S3 physician line (Summit and/or Alta Bates Campus) 855-398-1641, Option 1, or email S3Chart CompletionTeam@Sutterhealth.org.
  3. Call or email the HIM Manager (Summit and/or Alta Bates Campus) Summit: 510-869-8741, or Email Stinnal@sutterhealth.org.

If there is a workflow issue we can assist with, please contact Patty Fitzgibbons, Physician Liaison, at 510-869-8339 (office) or 510-325-9618 (cell) or by email fitzp@sutterhealth.org.

 

 

Cosigning Verbal Orders – Setting Email Reminders

Verbal Order Email Reminder

Providers are able to receive email reminders when there are verbal orders in their In Baskets.  This requires a modification to the In Basket Settings.


  1. Click on In Basket from the main menu in EPIC.
  2. Click on Settings
  3. Click on Reminder Email
  4. Click the box to the left of “Subscribe with email address and,
    in the field to the right, type your email address
  5. Enter the Message Type “Verbal Order Cosign”
  6. Enter the Outstanding Days to the right of the Message Type

 

For assistance, please contact your EHR Physician Liaison, Patty Fitzgibbons, at 510-325-9618.

Thank you!

Quick Tips Cosigning Verbal Orders

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

 

 

For Same Day procedures, I recommend this method (before your leave the hospital) for 100% compliance! 

 MANAGE ORDERS

  1. Open the patient’s chart and select “Manage Orders” button.
  2. In the table of contents click “Cosign Orders.
  3. Click “Sign All Orders” to sign all the verbal orders.
  4. Click “Sign Section” or
  5. Use the “Sign” button for the individual order.This method will also allow you to cosign for other providers, i.e., the proceduralist or anesthesiologist.

 

For Inpatient/Overnight stays, doing this method 1X per day will keep you at 100% compliance!

 IN BASKET

  1. Click on the In Basket icon on the header bar
  2. Click the “x Chart Completion” folder.
  3. Single click on Cosign Needed message and the order details
    will appear to the right or below the message.
  4. Click the “Sign” hyperlink to the right on the order to sign

individual orders.

  1. Click the “Sign” button above the message to sign all the
    orders at once.

F. Click the “Refresh” button and the messages will drop off your
message list immediately.

PATIENT LISTS

This method requires you to have the “Cosign Ord” column in your patient list.  For assistance to update your list, contact Patty Fitzgibbons at 510-325-9618.

 This is great for docs who have multiple patients, i.e., hospitalists, intensivists.  It is also great for docs who are part of a group because providers can cosign for each other.

  1. Click on your MyPatient List and single click on a patient.
  2. Click on the “Cosign Ord” header.
  3. Click on the Cosign Orders Report.
  4. Click to Sign Section.

 

This method allows you to cosign orders on multiple charts in a very short period of time.  Providers can cosign for other docs in their groups. 

 

For assistance, please contact your EHR Physician Liaison, Patty Fitzgibbons, at 510-325-9618.

Thank you!

 

Verbal and Telephone Order Compliance SBAR

Posted on Sep 5, 2018 in Health Information Management | 0 comments

Situation:  In Q2 of 2018, Sutter Delta compliance for CMS Verbal and Telephone order was at 81%. In June, the order compliance was at 82%. According to TJC/CMS/Title 22, the requirement is that verbal orders are authenticated within 48 hours.  (ABSMC is at 83% compliance over the last 12 months.  We have not been able to move compliance in the right direction.)

TJC/CMS/Title 22

VERBAL ORDERS

·          Verbal orders are authenticated within the timeframe specified by law and regulation. Note 1: For hospitals that use Joint Commission accreditation for deemed status purposes: If there is no state law that designates a specific time frame for authentication of verbal orders, the verbal orders are authenticated within 48 hours

·          JCAHO RC 02.03. 07

·          CMS 482.24 (c) (iv)

·          Title 22 70263

 

Background:  In May, Sutter Delta has CMS Survey. Sutter Delta was cited for not compliant to TJC/CMS/Title 22 requirement of verbal orders signed within 48 hours. (CMS, CDPH and other regulatory agencies are making the rounds.  We are at risk for citation due to our low compliance.)

Assessment:  Questions arose regarding our physicians are aware of requirement on CMS Verbal and Telephone order. What tools and support we can provide to our physician to get orders signed within 48 hours.  (Currently, we have a unsigned VO/TO within 48 hours report that can be run daily.  The report has been sent out a few times a week to select providers since Delta was cited and when regulatory agencies are in the house)  The Delta Lean consultant is also compiling a daily graphs to track progress.  This is something we can look at implementing at ABSMC as well.  Examples of tracking tools attached.

Recommendation:  Sutter Delta created a team, which had CME, Dept. Chairs, physician liaison, Lean consultant and HIM lead to educate our physician on requirement of verbal orders signed within 48 hours. Initially, meetings were held daily and then moved to weekly.  The Physician liaison took the lead to call or text all the physician who were coming close of 48 hours of signage and explain the importance of order been signed within 48 hours. Medical Staff informed all physician regarding notifying HIM dept. when physician are going on vacation, so HIM can put chart on hold to prevent deficiencies aging. The compliance rate improved by 9% since June. We are currently at 91% compliance and our goal is to get to 95%.  (ABSMC created a VO workgroup 2 years ago and we have performed a lot of education to date through Medical Staff but it has not been enough to move us closer to our goal.   I recommend we look at expanding our workgroup to include our CMO, Medical Staff Department Chairs, Physician Liaison, Medical Staff Directors, Lean Consultant and Clinical Operations Team)

 

CMS Verbal & Telephone Order Compliance is on the Radar for CMS! 

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

CMS Verbal & Telephone Order Compliance is on the Radar for CMS!  VO/TO orders are required to be signed within 48 hours:

  • Current compliance is down at 81% through May. ABSMC benchmark for compliance is 90% or greater
  • Specialties with over 100 orders at 90% or greater compliance for the May

–              Emergency Medicine
–              Radiology Diagnostic and Interventional

  • Specialties with over 100 orders at 80% or greater compliance for May

–              Anesthesiology
–              Cardiothoracic Surgery
–              Critical Care Medicine
–              Hospitalist Medicine
–              Internal Medicine
–              Orthopedic Surgery
–              Physical Medicine and Rehab
–              Psychiatry

  • Specialties with over 100 orders: Opportunity for improvement

–              Cardiology
–              General Surgery
–              Hematology/ Oncology

Help make a difference! We are asking for your assistance in signing your VO/TO within 48 hours:

  • Please remember that you can sign orders for your colleagues.
  • Hardwire signing off on orders every day and before you go off shift.
  • Be survey ready now!

Suspension Criteria Change approved at March MEC:

  • As a reminder, HIM will begin suspending for all “Review” deficiencies for missing information starting the week of July 16. This includes:

–              Missing required content such as EBL or specimens removed
–              Missing or incorrect discharge dates
–              Missing final diagnosis or discharge summary content

History and Physical Reminders:

  • H&P is required to be recorded in the patient chart prior to surgery. This includes a scanned H&P
  • If H&P is within 30 days of the current surgery, provider is required to document the H&P interval update after admission but prior to surgery
  • If you are using your office H&P, please ensure you copy and paste your office H&P to the correct surgical encounter

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

Suspension Criteria Change Effective 6/18/2018

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

Suspension Criteria Change Effective 7/13/2018:

  • Summit MEC approved change 3/13/2018 in suspension criteria to include the following elements currently listed under “Review Deficiencies”:

Missing or incorrect Discharge / Admission Dates

Missing EBL, SPECIMEN

Missing Discharge Diagnosis

Missing Dispositions

Missing pre/post OP diagnosis

  • Please ensure you are completing these deficiencies within 14 days of receiving as they will now be included in suspension processing.
  • Coding queries are NOT included.
  • Please work with Patty Fitzgibbons, Summit Physician Liaison if you need assistance modifying your templates to include all required information.

Content requirements for Immediate Post-Operative note and Operative/Procedure Notes:

  • Is EBL and Specimen Removed required in ALL l Immediate Post Op notes and Operative/Procedure Notes, regardless of type of operative procedure
  • YES, per Sutter Licensing and Accreditation, the Estimated Blood Loss and Specimen removed should be included in both the Immediate Post Op progress note template and the Operative /Procedure Report template regardless of operation or procedure type.
  • If there is no blood during procedure, document “ no blood loss” or NA
  • If there is no Specimen Removed, document “none”
  • Please reach out to Patty Fitzgibbons- Summit Physician Liaison if you need assistance adding these requirement to your documentation templates.

History and Physical Information:

  • You may be asked for H&P if the analyst cannot find one attached to the correct surgical encounter. To avoid this please ensure the following:
  • If you are completing your H&P in the office, please ensure you are documenting the H&P on the correct surgical encounter. You may also copy and paste your office H&P into the correct surgical encounter.  If you are using an office H&P or copy and paste functionality, please ensure your H&P dates are within 30 days of the patient admission.   H&P outside of this 30 day time period do not meet regulatory standards.