Health Information Management

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
stinnal@sutterhealth.org

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
stinnal@sutterhealth.org
(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

Suspension Reinstated!

Posted on Nov 6, 2017 in Health Information Management | 0 comments

Suspension for delinquent medical records has been reinstated effective Nov 2, 2017.  All providers will continue to receive notification of deficient and delinquent medical records to their specified notification preference on file.  If you would like to change your notification preference, please reach out to stinnal@sutterhealth.org

Transcription. What happens if I mark all my dictation STAT?

Marking all dictated reports STAT may cause a delay in the turnaround times of reports that are truly STAT dictations.  In order to help us serve you and our patients better, please only mark stat those reports that are needed on an urgent basis such as a Transfer Summary. Your attention to this detail is greatly appreciated.

What are the standard Work types for the Summit Campus and Turn-around times (TAT) for dictation?

WT Code              Work type           TAT (HRS)

58           Behavioral Health Consult            4
18           Cardiac Cath       12
20           Cardiology Procedure    12
3              Consultation      4
8              Discharge Summary        8
9              ED Provider Note             12
98           Emergency Medicine Consult (old name ED Consultation)             4
26           EEG        12
40           Electrophysiology Study Report 12
2              History and Physical        4
12           Interim Summary             12
4              Operative Report             12
3           Outpatient Consultation               4
52           Pre-Operative History and Physical          4
5              Procedure Report            12
41           Pulmonary Function Test – PFT  12

Got POLST Form?

Health Information Management (HIM) at the Summit and Ashby campus is working in collaboration with our community Nephrology groups to help ensure the patient POLST form is received and scanned to the patient chart.  A dedicated fax cover sheet has been developed for our Provider’s to complete and send along with the updated POLST form that is completed in the Provider office.  Once received by HIM, the POLST form will be scanned to the patient chart.  The POLST form cannot be scanned to a patient chart that has not been seen at a Sutter Facility.  If you are interested in starting a similar process, please feel free to reach out to Alisa Stinn, HIM Manager at Summit.

Alisa Stinn, RHIT

Health Information Manager / HIM Leader
Alta Bates Summit Medical Center-Oakland Campus
stinnal@sutterhealth.org
(Office) 510-869-8741
(Cell) 510-381-5181
(Fax)  510-869-8856