NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS



REVISIONS TO POLICY STATEMENT: YES NO OTHER REVISIONS: YES NO

APPLICATION:

This applies to the Medical Records Department

POLICY:

It is the policy of Northpointe Behavioral Healthcare Systems Medical Records Department to ensure timely and accurate transcription of digitally recorded medical reports.

PURPOSE:

To provide accurate transcribed medical information to staff for coordination of services in a timely manner.

PROCEDURE:

After each medical appointment the physician/nurse practitioner is required to dictate a report using digital recording equipment (Psychiatric Evaluation, Medication Review, etc.). The Practitioner will dictate reports following each service recipient session. Upon completion of dictation the digital recorder will be given to the nurse or other designated med records staff for downloading to a centralized dictation pool. Practitioner dictation is saved to individual folders by site and date.

Authorized Medical Records staff (Transcriptionists) will access the documentation via the Calendar LIST option which allows them to add the clinical document. The document will have a red dot when it is completed and waiting for signature. A green dot appears once the document is signed.

Transcriptionists can easily track missed dictation using this method, as kept appointment would be missing documentation on the list.

Policy requirements for these documents should minimally include the following:

Medication Review

Individual’s name, identification number (MCOID), date of service, start time, stop time, assessment, lab (if indicated), medications (describing reason for medication and side effects), the diagnosis (code number and nomenclature), indicate to whom copies should be sent (primary care physician, school, workplace, etc.).

Psychiatric Evaluation

Individual’s name, date of evaluation, identification number (MCOID), date of birth, age, gender, start time, stop time, identification, presenting problem, history of present illness, past medical history and treatment, social history, medications, lab results, mental status examination, diagnostic impressions (DSM-IV-TR) including nomenclature, treatment plan and indicate to whom copies should be sent (primary care physician, school, workplace, etc.)

Creation & Completion of Electronic Med Review/Psychiatric Evaluation Documents

Transcriptionist opens the electronic medical chart, MEDICAL SERVICES tab, and chooses either the Medical Evaluation Notes or Psychiatric Evaluation link and creates a new document. The Practitioner dictates using a template of the online document and the Transcriptionist follows the dictation and completes the document. They enter SEND COPY to link indicating internal/external routing, create the SAL (service activity log), and

SIGNATURES link with the Practitioner’s name. The signature link automatically routes the document to the

Practitioner’s TO DO mailbox indicating the document is ready for review and signature. The Practitioner may return the document for correction if needed.

All outgoing transcriptions are logged according to HIPAA regulations and are either automatically logged online when the Practitioner chooses from the External Address Book or manually online by Med Records by going to the Disclosure Log link and Add External Copy Request. Medical Records staff will confirm current Release of Information is in the chart before mailing/faxing documents from the Medical Records Queue.

Medical Record documents have a turnaround time of 48 hours, as a general rule. However, urgent requests will be honored. The Medical Records Manager has the ability to monitor the Dictation Pool and add/decrease transcriptionists accordingly.

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