Health Information Management

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

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!