Thomas Thomas Thomas Jefferson Jefferson Jefferson ...hospitals.jefferson.edu/files/nursing-orientation/advanced... · home or recent homecare for wound or trach Surgical Care Improvement

National National National National Hospital Quality Measures (NHQM)Hospital Quality Measures (NHQM)Hospital Quality Measures (NHQM)Hospital Quality Measures (NHQM)

The NHQM were developed and implemented to support an improvement in the quality of healthcare and patient outcomes. Reported at: www.hospitalcompare.hhs.gov. For all of the measures below, DOCUMENT a reason if not administering the recommended care.

Acute Myocardial InfarctionAcute Myocardial InfarctionAcute Myocardial InfarctionAcute Myocardial Infarction

Document the following: � Reason for not prescribing aspirin on arrival or at

discharge � Reason for delay in PCI � Most recent EF% or description of LVSF � Reason for not prescribing ace/arb (for EF<40%) � Reason for not prescribing beta blocker � Reason for not prescribing statin at discharge

PneumoniaPneumoniaPneumoniaPneumonia

Document the following: � Dates of recent inpatient hospitalization (HAP) Patient transfer from a skilled facility/rehab/nursing home or recent homecare for wound or trach

Surgical Care Improvement Program (SCIP)Surgical Care Improvement Program (SCIP)Surgical Care Improvement Program (SCIP)Surgical Care Improvement Program (SCIP)

Document the following: � Presence of infection prior to surgery � Reason to extend antibiotics past 24hr (48hr for

CABG/Other Cardiac Surgery [OCS]) after Anesthesia End Time. Documentation must be present by end of post op day 2 (3 for CABG/OCS)

� Reason for not administering beta blocker during the “perioperative period” (from the day prior to surgery through postoperative day two) for patients on beta blocker medication at home

� Reason for not ordering mechanical AND/OR pharmacologic VTE prophylaxis (surgery type specific). Documentation must be found within timeframe of arrival to 24hr after anesthesia end time (CABG and OCS exempt)

� Reason for continuing urinary catheter past POD 2 Examples of acceptable reasons:

o “Keep catheter for strict I/O” o “Keep catheter while patient is non-

ambulatory” “Keep catheter until POD 3”

Care Coordination (AMI, HFCare Coordination (AMI, HFCare Coordination (AMI, HFCare Coordination (AMI, HF, Pneumonia, Pneumonia, Pneumonia, Pneumonia))))

Please order Care Coordination in JeffChart and enterPlease order Care Coordination in JeffChart and enterPlease order Care Coordination in JeffChart and enterPlease order Care Coordination in JeffChart and enter diagnosisdiagnosisdiagnosisdiagnosis on on on on JeffChart JeffChart JeffChart JeffChart Problem ListProblem ListProblem ListProblem List

HHHHospital Acquired Conditions (HACs)ospital Acquired Conditions (HACs)ospital Acquired Conditions (HACs)ospital Acquired Conditions (HACs)

The following conditions, if not present on admission, (POA) are considered HACs and will not be reimbursed as a complication/co-morbidity under the CMS Inpatient Prospective Payment System:

1) Foreign Object Retained After Surgery 2) Air Embolism 3) Blood Incompatibility 4) Stage III and IV Pressure Ulcers 5) Falls and Trauma 6) Manifestations of Poor Glycemic Control

a) DKA/HHNK/HHS b) Hypoglycemic Coma c) Secondary Diabetes with Ketoacidosis d) Secondary Diabetes with Hyperosmolarity

7) Catheter-Associated Urinary Tract Infection (CAUTI)

8) Vascular Catheter-Associated Infection 9) Surgical Site Infection following:

a) CABG - Mediastinitis b) Bariatric Surgery c) Orthopedic Procedures

10) DVT/Pulmonary Embolism following Total Hip/Knee Arthroplasty

Present on Admission (POA)Present on Admission (POA)Present on Admission (POA)Present on Admission (POA)

Document whether secondary conditions not listed on the H&P were: POA – Not POA – Unable to Determine if POA

Patient Safety Indicators (PSIs)Patient Safety Indicators (PSIs)Patient Safety Indicators (PSIs)Patient Safety Indicators (PSIs)

� Maintained by AHRQ, a sister agency to CMS � Focus on the quality of care of adults inside hospitals � Are based on administrative (coded) data � Are publicly reported � Examples of PSIs include:

o Death in low mortality DRGs (PSI 2) o Foreign body left in during procedure (PSI 5) o Iatrogenic pneumothorax (PSI 6) o Postoperative respiratory failure (PSI 11) o Postoperative PE or DVT (PSI 12) o Accidental puncture and laceration (PSI 15)

Palliative CarePalliative CarePalliative CarePalliative Care

Always document Palliative Care, Comfort Care, End-of-Life Care or Terminal Wean when applicable!

For questions or to schedule an in-service contact: Tricia Norton RN, BSN, CCDS

215-955-0139

Electronic version available on intranet: http://tjuh4.jeffersonhospital.org/clinical_reference_cards/index.cfm

Thomas Thomas Thomas Thomas Jefferson Jefferson Jefferson Jefferson University University University University HospitalHospitalHospitalHospital

Clinical Documentation Improvement Clinical Documentation Improvement Clinical Documentation Improvement Clinical Documentation Improvement ProgramProgramProgramProgram

Program Goal: Accuracy and Quality within the Inpatient Medical Record in order to support: � Severity of Illness � Accuracy of Publicly Reported Data � Quality Indicators � Coding Accuracy (the assignment of codes is based on

physician documentation!)

General Medical Record Documentation InformationGeneral Medical Record Documentation InformationGeneral Medical Record Documentation InformationGeneral Medical Record Documentation Information

Make sure that ALL entries are legible and include: � Signature � Date � Time

Dangerous Abbreviations: DO NOT USEDangerous Abbreviations: DO NOT USEDangerous Abbreviations: DO NOT USEDangerous Abbreviations: DO NOT USE

� U � IU � QD � QOD

� MS � MgSO4 � Use of trailing zero 1.0 � Failure to use leading zero 0.1

Gold Standards of Physician DocumentationGold Standards of Physician DocumentationGold Standards of Physician DocumentationGold Standards of Physician Documentation

Always Document (in diagnosis form): � Reason for Admission

o The cause of presenting symptom(s): o If cause not definitive, please indicate

“suspected” ,“possible”, “likely” etiology o Clarify, after testing, any suspected

diagnoses that have been eliminated � All Secondary Conditions. Include:

o Chronic conditions o The acuity of the current episode (acute,

chronic, or acute on chronic) o The clinical significance of abnormal tests

� Vaccine status: include on H&P � Avoid the use of arrows/symbols. For example:

o Use Hyponatremia instead of ↓Na o Use UTI instead of +UA o Use C-Dif Colitis instead of +C-Dif o Use Anemia (w/type) instead of ↓H/H o Use Hypotension instead of ↓BP

NeurologyNeurologyNeurologyNeurology

INSTEAD OF PLEASE CONSIDER

R/O CVA � Ruled IN or Ruled OUT (if ruled

out include suspected cause of presenting S/S)

?TIA � Cerebral embolism/thrombosis

w/o infarction L/R Sided Weakness

� L/R hemiparesis/hemiplegia

MS Changes (clarify etiology)

� Acute delirium � Acute dementia � Encephalopathy (type) � Coma

Seizure � Type/recurrence � Status Epilepticus

Brain swelling/ Mass effect

� Cerebral edema � Vasogenic edema

PulmonaryPulmonaryPulmonaryPulmonary


Hypoxia /SOB/ Respiratory Distress

� Acute respiratory failure � Chronic respiratory failure � Acute pulmonary insufficiency

following surgery/trauma � Acute respiratory failure requiring

mechanical ventilation � Acute respiratory distress

Pneumonia � Aspiration Pneumonia � Viral Pneumonia � Bacterial Pneumonia (organism)

Pulmonary Edema

� Document acuity

Pleural Effusion

� Document etiology

COPD/Asthma

� Acuity � Type (if known) � Acute or chronic respiratory failure

(if applicable) � VDRF (if applicable)

HematologyHematologyHematologyHematology


Anemia

� Acute/chronic blood loss anemia � Acute/chronic iron deficiency � Anemia of chronic disease � Anemia (type) d/t chemotherapy � Pancytopenia

↓H/H post-op

� Acute blood loss anemia � Precipitous drop in hematocrit

CardiologyCardiologyCardiologyCardiology


Chest Pain

“Known”/ “suspected” / “likely” etiology: � GERD � Musculoskeletal � Accelerated angina

MI � AMI (location if known) � NSTEMI � STEMI

CHF

Include ACUITY and TYPE, e.g.: � Acute systolic CHF � Chronic diastolic CHF � Acute on chronic systolic and

diastolic CHF

ACS � AMI � Angina (specify)

Cardiomyopathy � Type � Component of heart failure this

admission? (specify CHF type)

Troponin Leak/ Bump

Etiology of elevated troponins: � AMI/NSTEMI � Other etiology

Syncope � Document suspected etiology

GI/HepatologyGI/HepatologyGI/HepatologyGI/Hepatology


GI Bleed � Document “known”, “likely,” or

“suspected” source of bleed

Heme + Stool � GI Bleed (source) � Melena

Esophagitis � Document acuity Cholecystitis � Document acuity Hepatitis � Specify acuity and type Liver Failure (ESLD)

� Etiology � Encephalopathy � Varices � Ascites

Infectious DiseaseInfectious DiseaseInfectious DiseaseInfectious Disease


Sepsis/SIRS/ Septicemia

� Document infection source � Causative organism � SIRS (etiology)

o Organ failure? (specify)

HIV/AIDS � Differentiate HIV+ vs. AIDS

Fever � Document suspected etiology

GenitourinaryGenitourinaryGenitourinaryGenitourinary


+ UA “Dirty” UA

� UTI � Catheter-associated/not

catheter-associated/unable to clinically determine?

Urosepsis (DO NOT USE!)

� Generalized sepsis originating from the GU tract

� UTI CKD � Document stage (1-5)

Renal Failure � ARF/Acute kidney injury � ESRD � ARF on CKD (stage)

Renal Insufficiency

� CKD with Stage � ARF/Acute kidney injury

FEN/MetabolicFEN/MetabolicFEN/MetabolicFEN/Metabolic

Please consider the following conditions: BMI > 40 (document associated condition)

� Obesity � Morbid obesity � Overweight

BMI < 19 (document associated condition)

� Malnutrition o Mild/Moderate/Severe

� Cachexia � Underweight

Diabetes

� Controlled vs. Uncontrolled � Document cause and effect

relationship between DM and: o Neuropathy/Nephropathy/

Retinopathy o Gastroparesis o Osteomyelitis/Ulcer o PVD/PAD

IntegumentaryIntegumentaryIntegumentaryIntegumentary


Ulcer/lesion/ wound

� Etiology � Type o Pressure ulcer o Diabetic ulcer

� Location � Stage � Present on admission status

Wound Debridement

� Excisional vs. non-excisional � Instrument used � Deepest level of tissue removed

Health Information Management

Sr. Director of HIM: Shiny George, extension 5-8948 Director of HIM Operations : Maryann Papa, extension 5-0894 Supervisor, Evening/Weekends Banae Morris, extension 5-0138 Locations: HIM Center City Satellite Department: 1950 Gibbon Bldg. 215-955-6627 Reception Area-Research/Studies, Dictation Room MHD Satellite Department: 215-952-9239 HIM DEPARTMENT HOURS 8 AM to 11:30 PM- Monday through Friday 9 AM to 9 PM-Saturday, Sunday and Holidays DEPARTMENT HOURS HIM Center City Satellite Department: 8 AM to 5 PM - Monday through Friday MHD Satellite Department: 8:30 AM to 5 PM – Monday through Friday If you need assistance, we have listed department personnel who can answer your questions concerning specific areas:

AREA CONTACT PERSON EXTENSION

Admisson/DischargeDates Medical Record Numbers

Jillian Neisser 5-6625

Birth Certificates

Tara Blevins

5-6629

Coding Questions

Dina Nedorost

5-3606

Chart Completion/Dictation Michele Wos

Deborah Zorio 5-0897 5-0895

Documentation Improvement

Tricia L. Norton

5-0139

Release of Patient Information

Doreen Kluska 5-0135

Research/Studies

Cindy Eaddy

5-6144

Cancer Staging

Oncology Data Services

5-6741

DOCUMENTATION TIP SHEET:DOCUMENTATION TIP SHEET:DOCUMENTATION TIP SHEET:DOCUMENTATION TIP SHEET:

“Top 20” Risk Factors Affecting Mortality Models“Top 20” Risk Factors Affecting Mortality Models“Top 20” Risk Factors Affecting Mortality Models“Top 20” Risk Factors Affecting Mortality Models

Risk FactorRisk FactorRisk FactorRisk Factor What to DocumentWhat to DocumentWhat to DocumentWhat to Document Other Pulmonary

� Acute or chronic respiratory failure � Post-traumatic respiratory insufficiency � Acute pulmonary edema � COPD: exacerbation? � Spontaneous pneumothorax � Indicate if present on admissionpresent on admissionpresent on admissionpresent on admission (POA) � [Avoid “VDRF” unless long-term vent] � Always document a diagnosis related to Always document a diagnosis related to Always document a diagnosis related to Always document a diagnosis related to

mechanical ventilation!mechanical ventilation!mechanical ventilation!mechanical ventilation!

Pulmonary Circulation Disease

� Primary pulmonary hypertension � Chronic pulmonary heart disease � Chronic pulmonary embolism

Shock (POA) � Specify type of shock � Indicate if POA

Congestive Heart Failure

� Acuity (acute/chronic/acute on chronic) � Type (systolic/diastolic/combined) � [Avoid “volume overload” if HF exists]

Other Neurological Disorders

� Petit/grand mal status/epilepsy - type � Alzheimer’s/senile brain degeneration � Parkinson’s disease � Multiple sclerosis/demyelinating disease � Cerebellar ataxia � Aphasia (not late effect of CVA)

Brain/Spinal (POA)

� Encephalopathy/type � Brain compression/

herniation � [Avoid “midline shift”] � Coma

� Anoxic brain damage/injury

� Cerebral edema � Indicate if POA

Paralysis � Hemi-/quadri-/para -plegia/-paresis

� [Avoid “left sided weakness”]

� [Avoid “Left: 0/5, 0/5”]

Metastatic CA � Specify primary and all metastatic sites

Coagulopathy � Congenital/acquired factor deficiency � Thrombocytopenia (w/suspected type) � Hypercoagulable state/coagulation defect

� [Avoid “abnormal coags” or “↑INR”]

Anemia � Acute/chr. blood loss � Anemia of chr. dis.

� Iron deficiency � [avoid “↓Hgb”]

Sepsis/SIRS � known/suspected source & organism � POA? Not POA? UTD if POA? � [Avoid “bacteremia/+Bcx” if sepsis exists]

Liver disease � Indicate acuity and type of hepatitis � Specify acuity and cause of liver failure � Indicate if POA

Renal failure/ kidney disease

� Acuity/stage of CKD � ARF? AKI? ATN?

� POA? � [Avoid “↑↑Cr”]

Fluid & Electrolyte Disorders

� Hypo/hyperkalemia � Hypo/hypernatremia � Dehydration/vol.overload

� Acidosis/type � Alkalosis/type � [Avoid “↓NA”]

� Malnutrition � Obesity/morbid � Cachexia/sev. malnut.

� BMI <19 or >40

� Depression � Alcohol/drug abuse � Psychoses/ type/acuity

�

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How the Process Works Essential Facts

The most important operating details for the physician to be aware of are:

• An inventory of incomplete records for each

physician is done each Wednesday.

• Resident and Attending Physicians responsible for dictation of operative reports must dictate prior to patients moving to the next level of care.

• Residents have fourteen (14) days to complete all other responsibilities. Resident’s fourteen day count will be initiated one day post chart allocation.

• The Attending Physician is ultimately responsible for completion of the medical record within 30 days.

• Records which have not been completed within these time frames will be deemed delinquent.

• An electronic notice is sent immediately after the inventory to each attending and house staff physician and the appropriate Department Chairman listing the incomplete and/or delinquent records by patient name, medical record number and discharge date.

• A fine is levied against the physician’s Clinical Service for each record found delinquent at the time of inventory. Once the record has become delinquent, the fine must be paid for that period.

• In the event of a physician’s illness, records will not be counted as delinquent for either attending or house staff physicians if the Chart Completion Area is notified promptly (extension 5-0895 or 5-0897).

• Attending and House Staff physicians must send, in advance, written notice of vacation if they wish to avoid delinquent records and the resultant fines. The notice should be sent to the Director of HIM Operations, Suite 1950 Gibbon Bldg. All records held in abeyance must be completed during the inventory cycle that follows the vacation.

• The Department Chairman may charge fines to the responsible physicians rather than pay them out of Department funds.

Rationale The purpose of the medical record requirements is to ensure prompt completion of medical records which enhances patient care by improving the availability of clinical information for recently discharged patients; secondarily it enhances the management of patient accounts. In addition, timely medical record completion is a regulatory requirement. The Joint Commission mandates all medical records to be completed within 30 days of discharge.

Additional Operating Details Paper records of discharged patients are received in Health Information Management within 24 hours of discharge.

• The records are reviewed for quantitative deficiencies, i.e. signed and dated History and Physicals, dictated and signed operative reports (when applicable), final progress note/discharge order, and dictated and signed discharge summaries.

• If deficiencies are noted, the records are assigned to the responsible physician(s) for completion according to the written schedules provided by the respective Clinical Services.

• Physicians are sent an electronic notice each Wednesday that lists all of their incomplete charts. Physicians can also log into JeffNotes Signature Plus to view the chart deficiencies on their list.

• The amount of the fine levied on delinquent records is $10.00 per delinquent record. Fines accrue weekly until the records are completed.

• Physicians incurring fines should pay them to his/her Department Chairman.

• Department Chairman are notified weekly of fines incurred for that week by members of their staff. Accrued fine information is forwarded to the Chairmen quarterly.

• Money collected from the fining process will be allocated to the Medical Staff Administration fund.

• Medical Staff Bylaws call for the suspension of privileges after repeated failure to complete medical records as outlined in the Record Completion Process.

JeffNotes Signature Plus Physician Quick Reference Guide

Login

1. From Internet Explorer, GO TO the Hospital Intranet site. http://tjuh.jeffersonhospital.org/. Website access must be through the Jefferson computer network.

2. CLICK the Clinician tab. 3. CLICK the JeffNotes Signature Plus link under Clinical

Applications. The 3M ChartView Login window appears. 4. From the 3M ChartView Login window, TYPE your USER ID in

the User Name field and PASSWORD in the Password field. Then CLICK the Login button. User ID is the same as a JeffChart User Number – a “P” or

an “R” followed by five numbers, i.e. P12345 or R12345.

Applications The following applications are available in JeffNotes Signature.

Provides the ability to search for a patient’s electronic medical record.

Provides a list of documents that need to be completed electronically.

Provides a list of documents that need to be dictated.

Navigating within Applications

There are panes throughout the applications. Re-size these panes by placing the cursor over the border between two panes (crosshair appears) and dragging to increase or decrease the size of a pane. The right pane displays extra information, which you have the ability to display or hide.

If the pane is unpinned, then it is hidden from view, except for a small edge, and only appears when you move the cursor over the edge.

If the pane is pinned, the pane is always visible. You may want to unpin the pane to provide more room for document viewing.

Changing your password

1. CLICK on the File menu and SELECT Change Password. 2. Enter the new password twice and CLICK OK.

ChartView – Retrieve Patient Documents 1. In the toolbar at the top of the screen, SELECT the Search

Field and type the Search Criteria. Then CLICK ‘Go’.

2. The correct patient will automatically populate or a select window will open displaying patients/visits that meet the criteria.

3. Click the plus sign (+) next to a patient to expand the results for that patient.

Expands all of the items in the list so you can see all of the items underneath.

Collapses all of the expanded items in the list so you see only the top-level items.

4. CHECK the box to the corresponding patient and CLICK Select.

ChartView – Document Tree

Please Note: ‘F7’ Opens all folders. ‘F8’ Closes all folders.

ChartView – Bookmark You can include more than one document at a time in the viewer. Each document is displayed on a different tab. To view more than one document: 1. Open the first document by clicking on it in the document tree. 2. To open the second document, right-click it in the tree and

SELECT Open in new tab.

If you want to view both documents at the same time:

1. Right-click the tab and SELECT a new vertical tab group or move to next tab group.

ChartView - Document Tree Icons

An Incomplete document.

A merged medical record.

ChartView - Toolbar Icons Monitor size or resolution will depend upon placement of the tools.

Document resizing tool. The cursor turns into a magnifying glass when moved across the document.

The drop- down allows the option to “flip’ the document vertically or horizontally.

The drop-down allows the option to rotate the page 90, 180, or 270 degrees.

The width of the document fits the width of the viewer pane.

The document height fits the height of the viewer pane.

Dictation List

When you first login, click on the Discharge Date column to sort if d/c date order. Dictations should be completed in 14 days.

Dictation is required.

Dictation is delinquent. Please note: Transcribed reports will not drop off your dictation list until they have been transcribed. Transcription turnaround is 24 hours for Operative Reports and 48 hours for Discharge Summaries.

Dictation List - Contesting a Dictation Contest a dictation if it was inaccurately assigned to you. 1. SELECT the dictation that you want to contest. 2. CLICK the Contest button. The Contested Dictation Window

will appear. 3. TYPE a personalized message explaining the reason for

contestation, or SELECT a Standard Message from the list by DOUBLE-CLICKING the appropriate message.

4. CLICK the CONTEST button.

Signature List -Editing a Transcribed Document The document appears in Viewer pane (Middle pane). 1. SELECT the Edit button in the Tools pane (Right pane). 2. Make the appropriate edits. 3. To save your changes, CLICK the Save and Sign button.

You will return to the signature list.

Click to open or close a folder

Click to view a document

Signature List – Completing a Query If you are requested to fill in information on a scanned document. 1. CLICK the Edit button. A text box will appear. 2. TYPE text in the box. 3. CLICK the Save button. 4. CLICK the Sign button.

Signature List - Updating the CC List Changes to the CC List can be made only in the Edit mode. 1. From the Document Viewer window, CLICK the Edit button and

the Edit CC For Documents window appears. 2. TYPE all or part of the provider’s last name in the Provider field

and CLICK the Search button. All providers matching the search criteria appear in the MD List.

3. SELECT the appropriate provider’s names(s) and then CLICK

the button to add the provider to the CC List. Do NOT select the Include Address in Document

checkbox. If a doctor’s name is not found, send a message (see

below “Sending a Message”) to HIM identifying the doctor to whom you would like a courtesy copy sent. Please include the doctor’s FULL name and address.

4. CLICK the OK button to save changes to the CC List. 5. Once the document appears in the edit mode again, CLICK

Save and Sign. Note: TJUH does not send courtesy copies to Residents.

Signature List - Receiving a Message from HIM

If blanks exist in a transcribed document, HIM will attach a message to the document. The message icon will appear in the Signature List and the message automatically appears above the document. Messages sent to the Resident who dictated will also appear in the Attending’s Signature list. The message will indicate “Dear Resident”. 1. Read the message. 2. If you agree with HIM, CLICK the CLEAR button to clear the

message, then CLICK EDIT to make any changes. 3. CLICK Save and Sign. 4. If you disagree with the message, TYPE a message to HIM and

CLICK the Send button. Please Note: Documents that have messages attached cannot be signed.

Signature List - Sending a Message to HIM

Sending a message regarding a document may be necessary if a document is allocated to the wrong provider. 1. While viewing a transcribed document, CLICK the Message

button. The ESA Message Window appears. 2. TYPE the message, then CLICK the Send button to send it to

HIM.

Signature List - Finalizing Documents After you have reviewed your documents, these documents are now “flagged” for finalization. The last step is to Finalize.

1. CLICK the button, which is in the left pane below the worklist.

2. A prompt appears asking to verify that you want to finalize all flagged documents. TYPE in your password and CLICK Yes to proceed with finalization.

3. Finalized documents will drop off your signature list. . 4. If you try to log off or exit the application before finalizing

flagged documents, you will receive a message indicating that there are items pending finalization.

5. CLICK Yes to proceed with finalization.

Signature List - Document Status Icons These icons in the document list provide information about the document statuses.

Document ready for review or signature.

Incomplete, unsigned transcribed document with a message from HIM (red dot on the envelope).

Unsigned document with provider originated message (green dot on envelope).

Signed document and pending finalization (red check mark).

Any of the above with a red plus sign (+) is an addendum.

Reviewed by resident waiting for Attending Signature.

Signature List - Other Useful Functions

This lists all your responsibilities to complete your charts.

This will display the electronic medical record.

For Assistance: (215) 955-0897

or (215) 955-0895

Signature List - Document Editing Tools The main function of ESA is signing documents. There are also tools for editing and other actions.

Marks a document for review. This is optional for Residents

Marks a document as signed.

Allows you to undo or make changes on pending documents marked as reviewed before finalizing the status.

Opens a window for editing an unsigned, transcribed document on signature list.

Opens a message window. You can type in information regarding reason for sending back to transcription.

Skips the next transcription document on the worklist.

Allows an addendum to be added to report.

Moves to the previous transcription document on the worklist.

Signature List – Mark up Tools

The following tools can be used to add annotations to scanned documents.

Add an arrow to the document.

Draw a circle.

Create a note to a document.

Add a checkmark.

Draw freehand lined.

Add text to a document.

RULES & REGULATIONS OF THE MEDICAL RECORD COMMITTE

https://jeff.tjuh.net/tjuh3/med_recs_rules_regs/

- 1 -

Date: 4/21/2012 Confidential and Proprietary to Thomas Jefferson University Hospitals, Inc.

Policy No: CC-01 Effective Date: 04/01/13 Revision Date:

DEPARTMENT POLICIES & PROCEDURES

Category: Medical Record Completion Title: Medical Record Completion and Suspension Policy Applicability: Thomas Jefferson University Hospitals, Inc. (TJUH) Contributors/Contributing Department; Executive Committee of the Medical Staff; Medical Record Committee, Office of Medical Staff Affairs, Office of General Counsel

PURPOSE

The purpose of this policy is to ensure prompt completion of medical records which enhances patient care by improving the availability of clinical information for recently discharged patients; secondarily it enhances the management of patient accounts. In addition, timely medical record completion is a regulatory requirement.

POLICY

Medical records must be completed within thirty days (30) of discharge. House Staff and Attending Physicians responsible for documentation of operative reports shall document immediately after surgery, prior to the patient moving to the next level of care. A dictated operative or procedure report must be completed following the surgery. House Staff have fourteen (14) days from the date of discharge to complete all other responsibilities. Attending Physicians and Dentists have thirty (30) days from the day of discharge to assure that all responsibilities are fulfilled, whether the responsibilities are assigned to a member of the House Staff or the Attending Physician. Records which have not been completed within these time frames are delinquent and subject to assessment of fines. The amount of the fine levied on delinquent records is $10.00 per chart, per week. Fines accrue weekly until the records are completed. Failure to meet these requirements call for suspension of admitting privileges as per Medical Staff Bylaws (Section 8.8-6) PROCEDURE

- 2 - A. Definition of Incomplete or Delinquent Record

A medical record not completed within 30 days of discharge is considered a “delinquent record”.

1. A dictated discharge summary may be delegated to house staff or auxiliary health care

providers within the scope of their privileges and must be signed, dated and timed. Discharge summaries are required for all inpatient records with length of stay of 48 hours or more and for all deaths, against medical advice (AMA) discharges and transfers regardless of length of stay.

2. The attending physician must review and sign all discharge summaries within 30 days from chart assignment. Signature process will be completed via Electronic Signature Authentication (ESA) within the electronic medical record (JeffNotes Signature Plus).

3. When applicable, operative reports must be completed, signed and made available in the medical record by the operating/responsible physician.

A medical record is not complete until all of the above conditions have been met.

B. Record Completion Procedure

1. Hardcopy portions of the medical records of discharged patients are retained on the

patient care unit until the patient leaves the unit. The medical records are then retained in a secure place on the patient care unit until the Health Information Management Department personnel can pick up the record. Medical Records must be made available for Health Information Management to pick up within 24 hours of discharge.

2. Hardcopy portions of the medical records of discharged patients may not be removed

from the patient care unit. 3. Electronic medical records of discharged patients will be available for completion

electronically via JeffNotes Signature Plus.

4. Therefore, no original, hard copy medical record will leave the institution except upon subpoena, court order or statute or the specific written authorization of the Hospital.

C. Notification of Delinquent Record/s and Administrative Suspension of Admitting

Privileges Procedure

1. Thirty (30) days are allowed for medical record completion.

2. Incomplete record status reports for all medical staff will be communicated weekly to the appropriate Clinical Chair.

- 3 - 3. A medical record is deemed delinquent on the 31st day after the record/s has been

assigned to the responsible attending physician. Delinquency notices will be communicated to each attending physician and to the appropriate Clinical Chair. A weekly notice, with a list of any incomplete records, will be sent to the

attending physician by Health Information Management via email. 1st Notification of “Incomplete record/s” is sent to attending and resident (if

applicable) on the first Wednesday after chart deficiency chart assignment. The notification is sent via email.

2nd Notification of “Incomplete record/s” sent to attending and resident (if applicable) on the second Wednesday after chart deficiency chart assignment. The notification is sent via email.

3rd Notification of “Incomplete record/s” sent to attending and resident (if applicable) on the third Wednesday after chart deficiency chart assignment. The notification is sent via email.

Final Notification of “incomplete records” and impending suspension is mailed out to the Attending via certified mail on the third Wednesday after chart deficiency chart assignment. Notification will also be sent to the Department Chair.

4. If after the 30 day completion period, the delinquent record count still remains at one (1) or more, the Office of Medical Staff Affairs will be notified by the Director of Health Information Management that suspension is required. Once HIM Department notifies the Office of Medical Staff Affairs that suspension is warranted, the Medical Staff Office will change the physician's designation in the database which feeds into JeffChart. This change prevents the physician from admitting a patient. Suspension Letter will be mailed out to the attending physician by the Office of Medical Affairs via Certified Mail.

5. Upon completion of all available records, the Director of Health Information Management will notify the Director of the Office of Medical Staff Affairs that the suspension may be lifted. Reinstatement of privileges will be done on the next business day.

6. Once HIM Department notifies the Office of Medical Staff Affairs that suspension is reinstated, Office of Medical Staff Affairs will re-activate the physician in the database so that admitting privileges are restored. This requires an overnight upload of information to JeffChart; so privileges are not restored until the day after HIM Department notifies the Medical Staff Office. Reinstatement Letter will be mailed out to the attending physician by the Office of Medical Affairs.

7. The suspension letter becomes a part of each physician’s permanent file and will be used as part of the documents reviewed during the Medical Staff reappointment/re-credentialing process.

8. Physicians may request an extension of time to complete records if they will be absent for more than five (5) days of the allotted time. The request must be submitted in writing, to

- 4 - the Director of Health Information Management Operations prior to the completion deadline.

Attachment(s): Attachment A – Weekly Incomplete Medical Record Notification Attachment B – Final Notification of Incomplete Medical Record/s and Impending Suspension Attachment C – Notification of Suspension Attachment D – Notification of Reinstatement Original Issue Date: April 2013 Revision Date(s): Review Date(s): Responsibility for maintenance of policy: Health Information Management Administration

(Signature on File)

Approved by: Shiny B. George MS RHIA Senior Director Health Information Management .