Health Information Management

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 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.

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

HIM Reminders

Posted on Apr 6, 2018 in Health Information Management | 0 comments

HIM Reminders:

  • Summer is around the corner. Please inform the HIM Department if you are planning a leave or vacation. HIM will place all chart deficiencies on hold while you are out. It is advised that you complete and sign all records before you leave.
  • Please sign your Verbal orders within 48 hours. This includes canceled and or discontinued orders which are currently counting towards our compliance rate.

Alisa Stinn, RHIT
Health Information Manager / HIM Leader
Alta Bates Summit Medical Center-Oakland Campus
(Office) 510-869-8741
(Cell) 510-381-5181
(Fax)  510-869-8856

Provider Query Response

Posted on Apr 6, 2018 in Health Information Management | 0 comments

Electronic Access to POLST Launches February 6, 2018

Posted on Feb 6, 2018 in Health Information Management | 0 comments

On Feb. 6, 2018, we will launch system-wide a comprehensive software solution to capture, store, and access Physician Orders for Life-Sustaining Treatment (POLST) forms. POLST forms are vital to ensure that we meet patients’ end-of-life wishes. This technology will help Sutter Health providers navigate conversations with patients and families, accurately document patient preferences and easily access POLST forms.

POLST forms allow people with serious, life-limiting illnesses to document their care preferences. However, the lack of electronic access to POLST has made it difficult for providers to find and access patients’ documents, especially during emergencies. In paper form, patients’ end-of-life wishes are accurately documented only about 30 percent of the time and about 25 percent of paper forms have an avoidable error that renders them unusable.

This new robust platform from Vynca, Inc. ensures that documentation truly reflects patient preferences, supporting best practices for advance care planning. The platform makes completed documents easily accessible by multiple providers via the electronic health record, which eliminates redundant data entry, improves accuracy and saves time. For more information, click here for the FAQ, Flier, and Know Do Share.

ePOLST Registry

Posted on Feb 6, 2018 in Health Information Management | 0 comments