Sample Medical Records documentation



Sample Medical Records documentation

B. MEDICAL RECORDS

A. General Documentation Rules & Guidelines

1. General – The hospital initiates and maintains a complete and accurate medical record for every individual assessed or treated. (JCAHO IM 6.10 EOP #6; COP 482.24 (b); DOH 115.31 (a); DOH 119.24) The attending practitioner will prepare a complete and legible medical record for each of his or her patients. (COP 482.24 (c) (1) The contents of all the records should be enough to identify the patient, support the diagnosis, justify the treatment, document the results of treatment accurately, and promote the continuity of care among healthcare providers. (JCAHO IM 6.10 EOP #6; COP 482.24 (c); DOH 115.32 (a).

2. Inpatient History and Physical (H&P) Requirements- (JCAHO PC 2.120) A physical exam and medical history must be done no more than 30 days before or within 24 hours after an admission for each patient by the attending physician.[1]In order for H&P’s to be transcribed and available in the EMR and on the patient record within 24 hours after admission it is recommended that physicians dictate their H&P’s no later than 12 hours after admission. (JCAHO MS 2.10 EOP #7; JCAHO PC 2.120 EOP #2; COP 482.22 (c) (5) Ref: S&C-02-15 January 28,2002; DOH 115.32 (b) A history and physical completed outside of the hospital (within 30 days of the current admission) by a licensed independent practitioner at the hospital to which the patient is admitted may be used to fulfill the H&P requirement, so long as a durable, legible copy of the history and physical is made part of the patient record within 24 hours after admission. Or when a patient is readmitted to the hospital within 30 days of the date of admission for the same or related problem, the original history and physical may be utilized provided it was not completed more than 30 days prior to the admission date.

a. Interval Note Requirements- If the history and physical being utilized for a particular admission was done more than 7 days prior to the admission date, an interval admission note must be completed documenting any additions or changes to the original history and physical. The interval note must be written within 24 hours after admission.

3. Outpatient Surgery History and Physical (H&P) Requirements- (JCAHO IM 6.30) Before surgery there must be a complete history and physical on the chart of every patient and any indicated diagnostic tests and pre-operative diagnoses must be completed and recorded in the patient’s record. If the history and physical has been dictated, surgery cannot begin until the H&P has been transcribed and placed on the patient’s record. If the H&P has not been dictated, a written H&P must be recorded in the medical record prior to surgery. The contents of the H&P whether dictated or written must be consistent with the contents of the H&P as noted in section 7.

When practitioners do not record the H&P before an operative or invasive procedure or any diagnostic procedure requiring informed consent, the Hospital will cancel the procedure, except in emergencies or unless the attending physician/surgeon states in writing that such a delay would be detrimental to the patient. (JCAHO MS 6.3; JCAHO PE 1.8; JCAHO IM 6.30; email from JCOURT1345@ 2/9/04)

a. Interval Note Requirements- If the history and physical being utilized for a particular surgery was done more than 7 days prior to the surgery date, an interval note must be completed documenting any additions or changes to the original history and physical. The interval note must be written prior to surgery.

4. H&P’s Greater Than 30 Days Old- H&P’s that are greater than 30 days old will not be accepted. A new H&P will have to be performed by an appropriate licensed independent practitioner. (JCAHO web site Q&A’s August 28,2001; JCAHO PC 2.120 EOP #6)

5. Prenatal H&P Requirements- It is recognized that the prenatal patient is a special situation in that, in and of itself, the prenatal course of care is a planned, systematic updating of the H&P performed at the first visit throughout pregnancy. As such, the entire prenatal record can be utilized as the H&P, provided that it is updated to reflect the patient’s condition upon admission. (JCAHO Q&A) For all patients having a c-section a H&P is required prior to surgery. See Section 7 for H&P Content Requirements.

6. H&P Requirements For Any Patient Admitted For Dental/Podiatric Care- Any patient admitted for dental/podiatric care must have a H&P done and recorded by a physician member of the Medical Staff. The dentist/oral surgeon or podiatrist is responsible for the part of the H&P and any other documentation related to their specialty. (JCAHO MS 6.2.2) Podiatrists are responsible for the part of the patient’s H&P that relates to podiatry. (JCAHO MS 6.2.2.3) Qualified oral and maxillofacial surgeons may perform the medical history and physical examination, if they have such privileges, in order to assess the medical, surgical, and anesthetic risks of proposed operative and other procedure(s). (JCAHO MS 2.10) A qualified and credentialed Podiatrist or Dentist can independently perform all of the inpatient and outpatient H&P, if given those privileges through the medical staff process, subject to applicable state law. Under such circumstances the medical staff is to identify any high-risk patients that would require confirmation or endorsement of the H&P by a qualified surgeon. (JCAHO MS 2.10 Q&A Effective 12/22/00 Updated 8/5/02)

7. H&P Content Requirements-

a. Chief complaint. (COP 482.24 (c) (2) (iii)

b. History of present illness.

c. Relevant past, social, family history. (appropriate to the patient’s age)

d. Inventory by body systems or review of systems.

e. Physical Exam. (JCAHO MS 2.10; JCAHO IM 6.30)

f. Conclusions/impressions drawn from the history & physical.

g. A treatment plan.

8. Operative Documentation Requirements- In addition to the history and physical, the medical record thoroughly documents operative or other procedures and the use of moderate or deep sedation or anesthesia. (JCAHO IM 6.30)

a. A provisional diagnosis is recorded before the operative procedure by a licensed independent practitioner (LIP) responsible for the patient. (JCAHO IM 6.30 EOP #1)

b. An operative progress note should be dated and timed and entered in the medical record immediately after the procedure and the note contains the following: (JCAHO IM 6.30 EOP #2)

i. Name of primary surgeon and assistants.

ii. Findings.

iii. Procedures performed.

iv. Description of the procedure.

v. Estimated blood loss.

vi. Specimens removed.

vii. Postoperative diagnosis.

c. Operative reports dictated or written immediately after a procedure record the following:

i. Name of the primary surgeon and assistants.

ii. Findings.

iii. Procedures performed.

iv. Description of the procedure.

v. Estimated blood loss.

vi. Specimens removed.

vii. Postoperative diagnosis. (JCAHO IM 6.30 EOP #3)

d. The completed operative report is authenticated by the surgeon and made available in the medical record as soon as possible after the procedure. (JCAHO IM 6.30 EOP #4)

e. Postoperative documentation records the following:

i. Patient’s vital signs and level of consciousness.

ii. Medications. (Including intravenous fluids)

iii. Blood and blood components administered.

iv. Any unusual events or complications, including blood transfusion reactions and management of those events. (JCAHO IM 6.30 EOP #5)

f. Postoperative documentation records the patient’s discharge from the postsedation or postanesthesia care area by the responsible LIP or according to discharge criteria approved by the Medical Staff. (JCAHO IM 6.30 EOP #6)

g. The use of approved discharge criteria to determine the patient’s readiness for discharge is documented in the medical record. (JCAHO IM 6.30 EOP #7)

h. Postoperative documentation records the name of the LIP responsible for discharge. (JCAHO IM 6.30 EOP #8)

9. Informed Consent- The physician will complete an informed consent form (and have the patient sign the form) for all procedures, investigative drugs therapyand other treatments for which policy requires informed consent. (COP 482.24 (c) (2) (v); JCAHO RI 2.40) An informed consent for surgery shall be part of the patient’s chart before the surgeon starts the surgery. (COP 482.51 (b) (2)

a. Duty of physicians- Except in emergencies, a physician owes a duty to a patient to obtain the informed consent of the patient or the patient’s authorized representative prior to conducting the following procedures: (DOH 40 P.S 1303.504)

1. Performing surgery, including the related administration of anesthesia.

2. Administering radiation or chemotherapy.

3. Administering a blood transfusion.

4. Inserting a surgical device or appliance.

5. Administering an experimental medication, using an experimental device or using an approved medication or device in an experimental manner.

a. Description of procedure- Consent is informed if the patient has been given a description of a procedure set forth in subsection (a) and the risks and alternatives that a reasonably prudent patient would require to make an informed decisions as to that procedure (40 P.S. Section 1303.504 (a), (b)).

10. Signatures- All entries in the medical record must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished. (JCAHO IM 6.10 EOP #1, DOH 115.33 (b), COP 482.24 (c) (i) (1), DOH 115.32) The responsible practitioner will accurately date and authenticate all clinical entries in the patient’s medical record. (JCAHO IM 6.10 EOP #2 and EOP #3, DOH 115.33 (e) Authentication can include signatures, Signature stamps (See on-line HIM P&P entitled Physician Stamp Signatures) written initials, or computer entry. (COP 482.24 (c) (1) (ii) Physicians may use electronic signatures to authenticate their transcribed reports. (See on-line HIM P&P entitled Physician Electronic Signature) Entries in patient charts concerning care (40 P.S.1303.511 (a.) [Act 13]) rendered shall be made contemporaneously or as soon as practicable after the care. Abbreviations and symbols in the patient record should adhere to the on-line abbreviation list. (DOH 115.33 (c) See Section 25 for specifics. It is preferred that practitioners will make all entries in blue or black ink using a ballpoint pen. The supervising physician must countersign all documentation by residents, nurse practitioners, and physician assistants. CNM’s do not have to have their documentation countersigned. (PA Bulletin Doc. No. 97-1212) At a minimum, the following must be authenticated: history and physical, operative report, consultations, and discharge summaries. (JCAHO IM 6.10 EOP #5) Verbal orders are the only entry that may be authenticated by someone other than the attending physician. For example, the physician covering rounds may sign verbal orders.

11. Faxed Signatures- Faxed signatures are an acceptable method of authorization (28 Pa. Code 115.23 (a)). When a faxed document/signature is included in the health record, the document with the original signature should be retrievable from the original source. (AHIMA Practice Brief: Maintaining a Legally Sound Health Record) Only under rare circumstances will the HIM Department fax incomplete records to physician offices to be signed and faxed back to the HIM Department. An example of a rare circumstance would be when a physician is not scheduled to return to the hospital for multiple weeks or when a physician or a group of physicians come to the hospital infrequently and their home practice is based outside of the Chambersburg/Waynesboro area. Physicians are strongly encouraged to use electronic signatures and to keep faxed signatures to a minimum.

12. Error Correction- Errors should be corrected as follows:

a. Draw a line through the entry- a thin pen line. Make sure the inaccurate information is still legible.

b. Sign and date the lined out entry using the current date and time.

c. State the reason for the error in the margin or above the note if room permits.

d. Document the corrected information. If the error is in a narrative note, it may be necessary to enter the correct information on the next available line/space documenting the current date and time and referring back to the incorrect entry.

Do not obliterate or otherwise alter the original entry by blacking out with marker, using whiteout, writing over an entry, etc. (AHIMA Practice Brief: Maintaining a Legally Sound Health Record) 40 P.S. 1303.511 (b) (2)[Act 13]).

13. Late Entries- (40 P.S. 1303.511 (b)(2) [Act 13]). When adding information to the chart which was not available or was otherwise not recorded contemporaneous with the events or shortly thereafter, late entries should be used. A late entry should:

a. Identify the new entry as a “late entry”.

b. Enter the current date and time.

c. Specify the date and time when the documented events occurred.

d. If the late entry is being used to document an omission, identify the source of the additional information as much as possible. (for example, where you obtained the information contained in the late entry)

e. When using late entries, document as soon as possible. There is no time limit to writing a late entry.

f. The late entry must contain the full signature of the author.

14. Addendums- An addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry. With this type of correction, a previous note has been made and the addendum provides additional information to address a specific situation or incident. An addendum is documented in the following manner:

a. Document the current date and time.

b. Write “addendum” and refer to the original entry.

c. Identify any sources of information used to support the addendum.

d. When writing an addendum, complete it as soon after the original note as possible.

15. Legibility- All entries in the health record must be legible. (49 Pa. Code 16.95 (a)) If an entry cannot be read the following steps should be taken:

a. The author should rewrite the entry on the next available line.

b. Define what the rewritten entry is for, referring back to the original documentation.

c. Legibly rewrite the entry.

Example: “Clarified entry of (date)” and rewrite, date and sign. The rewritten entry must be the same as the original. (AHIMA Practice Brief: Maintaining a Legally Sound Health Record)

16. References to Another Patient- If it is necessary to refer to another patient to describe an event, the other patient’s name should not be used. If necessary, the medical record number of the patient can be referenced. (AHIMA Practice Brief: Maintaining a Legally Sound Health Record)

17. Progress Notes- Practitioners will record progress notes at the time of observation. They should report (in pertinent chronological style) the patient's course in the hospital and reflect any changes in condition and the results of treatment. Practitioners will write, date and sign progress notes on a daily basis. All should be timed as well. The Hospital recommends that practitioners time the progress notes when they write multiple notes in a single day.

18. Patient Transfers- Transfer of a patient to another physician's service require awritten order by the transferring physician. The orders of transfer must be in the patient's medical record. Until physicians follow this sequence, the original physician is responsible for the patient.

19. Orders- The appropriate Medical Staff Department will formulate standing orders, which shall be reviewed by the Pharmacy & Therapeutics Committee and approved by the Medical Executive Committee. The attending physician will date and sign these orders. The Hospital will publish all standing orders and be available in each department at each nursing station. All orders for drugs and biologicals must be in writing and signed by the practitioner or practitioners responsible for the care of the patient. (COP 482.23 (c) (2) Practitioners will date and sign all non-standing orders or Physician Preference Protocol orders. (COP 482.24 (c) (2) (vi), DOH 115.33, DOH 107.62-107.65, DOH 107.61, JCAHO IM 6.50)

a. Oral/Telephone Orders- (DOH 107.62)

1. Oral orders for medication and treatment shall be accepted only under urgent circumstances when it is impractical for the orders to be given in written manner by the responsible practitioner. Oral orders shall be taken only by personnel qualified according to the medical staff bylaws who shall transcribe the orders in the proper place in the medical record of the patient. The order shall include the date, time and full signature of the person taking the order and shall be countersigned by a practitioner within 24 hours. If the practitioner is not the attending physician, he must be authorized by the attending physician and must be knowledgeable about the patient’s condition. (DOH 107.62) (JCAHO IM 6.50 EOP #2 and EOP #3)

2. The medical staff bylaws shall specify personnel who are qualified to accept oral orders and shall specify that acceptance of orders is limited to personnel listed in this subsection, with restrictions as noted: (JCAHO IM 6.50 EOP #1)

a. A licensed independent practitioner.

b. A professional nurse.

c. A licensed practical nurse.

d. A pharmacist who may transcribe oral orders pertaining to drugs.

e. A physical therapist who may transcribe oral orders pertaining to physical therapy regimens.

f. A respiratory therapist who may transcribe oral orders pertaining to respiratory therapy treatments.

g. A paramedic practicing under DOH 117.30 (relating to emergency paramedic services)

b. Outpatient Orders- Pending.

20. Consultations- (DOH 115.32 d; DOH 107.12 16) Consultants will dictate or record a consultation report within a timely manner. The consult report will record the pertinent findings of the examination of the patient and the consultant's opinions and recommendations. When operative procedures are involved, consultants will record the consultation note before the operation, except in emergencies so verified in the record. Physicians are encouraged to dictate their consultations so that they will be available in the MIG and the EMR.

21. Reports of Pathology, Clinical Lab Examination, Radiology, Nuclear Medicine, or other Diagnostic or Therapeutic Procedures- Diagnostic testing and procedures are performed as ordered. Diagnostic testing and procedures are performed in a timely manner as defined by the hospital. When a test report requires clinical interpretation, relevant information is provided with the request. (JCAHO PC.3.230 EOP #1 and EOP #2 and EOP #3) The radiologist or other practitioner who performs radiology services must sign reports of his or her interpretations. (COP 482.26 (d) (1) Signed x-ray reports of all examinations performed shall be made a part of the patient’s hospital record. (COP 482.25 (d) The hospital must maintain signed and dated reports of nuclear medicine interpretations, consultations, and procedures. The practitioner approved by the medical staff to interpret diagnostic procedures must sign and date the interpretation of these tests. (COP 482.52 (d), COP 482.53 (d) (2)

22. Final Diagnoses- The attending physician will record final diagnoses for all patient types (i.e., inpatients, outpatients) at the time of discharge. Practitioners will record the final diagnoses in full by dictating the discharge summary or writing the final diagnosis on the face sheet of the medical record . (DOH 115.32 f)

23. Discharge Summary Requirements- (DOH 115.32 f) Practitioners should dictate or record a discharge summary at the time of discharge, or as soon as practicable therafter. All patients who are admitted as inpatients must have a discharge summary dictated or recorded except normal newborns. For normal newborns with uncomplicated deliveries, or for patients hospitalized for less than 48 hours with only minor problems, a progress note may substitute for the clinical resume. The progress note may be handwritten. It must document the patient’s condition at discharge, discharge instructions, and follow-up care required. When a physician transfers a patient within the same organization from one level of care to another, and the caregivers change, the physician may substitute a transfer summary for the clinical resume. The transfer summary should briefly describe the patient’s condition at time of transfer and the reason for transfer. When the caregivers remain the same, a progress note may suffice. If the physician admits a patient as a full admit, but subsequently discharges the patient in less than 23 hours, the physician must dictate or record a discharge summary. The discharge summary/transfer summary will summarize concisely the following:

a. Reason for admission/hospitalization. (JCAHO IM 6.10 EOP #7, COP 482.24 (c) (2) (ii)

b. Significant findings. (JCAHO IM 6.10 EOP #7, COP 482.24 (c) (2) (vii)

c. Procedures performed and care, treatment, and services provided. (JCAHO IM 6.10 EOP #7)

d. Consultations performed. (COP 482.24 (c) (2) (iii)

e. Condition of the patient on discharge. (JCAHO IM 6.10 EOP #7, COP 482.24 (c) (2) (vii)

f. Instructions to the patient and family, as appropriate. (JCAHO IM 6.10 EOP #7, COP 482.24 (c) (2) (vii)

g. Principal diagnosis. (i.e. the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital) (COP 182.24 (c) (2) (viii)

h. Any additional secondary diagnoses, including complications and/or comorbities.

24. Autopsy Report- (DOH 115.32 f) When a pathologist does an autopsy, the practitioner should record a provisional anatomical diagnosis in the medical record within three (3) days. The practitioner should make a complete protocol part of the medical record within sixty (60) days. (CAP ANP.33150)

25. Symbols and Abbreviations- Practitioners will not use symbols and abbreviations in the medical record except those that HIM lists in the approved abbreviation list for the Hospital. (JCAHO IM 3.10 EOP #2) The approved abbreviation list can be accessed via the Summit Health intranet. (DOH 115.33 (c))

26. Time Off Notification- Practitioners should notify Health Information Management when they are to be on vacation to help avoid unnecessary suspension from delinquent medical records.

B. Contents of Medical Records – Each medical record contains, as applicable, the following information: (JCAHO IM 6.20 EOP #1; DOH 127.35; DOH 129.37; DOH 131.24; DOH 135.12; DOH 135.13; DOH 139.28; DOH 139.29;

1. Patient identification- e.g patient’s name, address, date of birth, and the name of any legally sound representative if any. (JCAHO IM 6.20 EOP#1 )

2. Legal status of patients receiving behavioral health care services. (JCAHO IM 6.20 EOP#1)

3. Emergency care provided to any patient prior to arrival, if any (JCAHO IM 6.20 EOP#1)

4. Documentation and findings of assessments (JCAHO IM 6.20 EOP#1)

5. Conclusions or impressions drawn from medical history and physical examination (JCAHO IM 6.20 EOP#1)

6. The diagnosis, diagnostic impression, or conditions (COP 482.24 (c) (2) (ii); JCAHO IM 6.20 EOP#1)

7. The reason (s) for admission or care, treatment and services (COP 482.24 (c) (2) (ii); JCAHO IM 6.20 EOP#1)

8. The goals of treatment and treatment plan (JCAHO IM 6.20 EOP#1)

9. Evidence of known advance directives (JCAHO IM 6.20 EOP#1)

10. Evidence of informed consent when required by organizational policy (COP 482.24 (c) (2) (v); JCAHO IM 6.20 EOP#1)

11. Diagnostic and therapeutic orders (JCAHO IM 6.20 EOP#1; JCAHO PC 3.230; COP 482.24 (c)(2)(vi)

12. All diagnostic and therapeutic procedures, tests and results (JCAHO IM 6.20 EOP#1; COP 482.24 (c) (2) (vi); DOH 115.32 (e)

13. Progress notes made by authorized individuals (JCAHO IM 6.20 EOP#1)

14. All reassessments and plan of care revisions, when indicated (JCAHO IM 6.20 EOP#1)

15. Relevant observations (JCAHO IM 6.20 EOP#1)

16. The response to care, treatment, and services provided (JCAHO IM 6.20 EOP#1)

17. Consultation reports (JCAHO IM 6.20 EOP#1; COP 482.24 (c) (2) (iii)

18. Allergies to foods and medicine (JCAHO IM 6.20 EOP#1)

19. Every medication ordered or prescribed (JCAHO IM 6.20 EOP#1; COP 482.24 (c) (2) (vi)

20. Every dose of medication administered, (including the strength, does, or rate of administration, administration devices used, access site or route, known drug allergies, adverse drug reactions, and any adverse drug reaction (JCAHO IM 6.20 EOP#1; COP 482.24 (c) (2) (iv)

21. Every medication dispensed or prescribed on discharge (JCAHO IM 6.20 EOP#1)

22. All relevant diagnoses/conditions established during the course of care, treatment, and services (JCAHO IM 6.20 EOP#1)

23. Records of communication with the patient regarding care, treatment , and services, for example, telephone calls or email, if applicable (JCAHO IM 6.20 EOP#1)

24. Patient-generated information (for example, information entered into the record over the Web or in previsit computer systems), if applicable (JCAHO IM 6.20 EOP#1)

25. Operative reports and other invasive procedures performed, using acceptable disease and operative terminology that includes etiology, as appropriate.

26. Documentation of complications, hospital acquired infections, and unfavorable, reactions to drugs and anesthesia (COP 482.24 (c) (2) (iv)

27. Conclusions at termination of hospitalization (DOH 115.32 (f)

28. Clinical resumes and discharge summaries, or a final progress note or transfer summary. A concise clinical resume included in the medical record at discharge provides important information to other caregivers and facilitates the continuity of care. For patients discharged to ambulatory (outpatient) care, the clinical resume summarizes previous levels of care (DOH 115.32 (f), COP 482.24 (c) (2) (vii)

29. Autopsy, if performed (DOH 115.32 (f)

30. Infant Footprints (DOH 115.25)

31. American Joint Committee on Cancer staging is assigned by the managing physician and recorded on a staging form in the medical record on all eligible analytic records. (ACOS and CPS standard 4.3)

C. Additional Contents of Outpatient Records (See section B for general requirements)

1. Emergency Care Unit Records - medical records from the Emergency Care Unit will contain the following:

a. Time and means of arrival (JCAHO IM 6.10 EOP#14)

b. Whether the patient left against medical advice (JCAHO IM 6.10 EOP#14)

c. The conclusions at termination of treatment, including final disposition, condition, and instructions for follow-up care. (JCAHO IM 6.10 EOP#14)

d. Notation that a copy of the record is available to the practitioner or medical organization providing follow-up care. (JCAHO IM 6.10 EOP#14)

e. Order by the physician for all diagnostic related tests. (Audio Conference: Diagnostic testing and medical necessity in the ER: How to comply and get full reimbursement)

f. Orders are signed off by the performing RN or tech. (Audio Conference: Diagnostic testing and medical necessity in the ER: How to comply and get full reimbursement)

g. Interpretation as appropriate. (Audio Conference: Diagnostic testing and medical necessity in the ER: How to comply and get full reimbursement)

2. Outpatient Surgery – (See section B for general requirements)

3. Observation Records – (See section B for general requirements)

a. Order that clearly specifies admission to outpatient observation status.

4. Outpatient Clinic Records- (See section B for general requirements)

a. Outpatient orders- Pending.

5. Outpatient Port Flushes and Infusions-

a. Face Sheet.

b. Physician Script/Order with diagnosis.

c. Consent for examination and treatment.

d. Clinical documentation.

D. Definition of a Medical Record Delinquency - A record will be delinquent if it has not been completed in its entirety within 30 days post discharge or the date of the encounter. (JCAHO IM 6.10 EOP #9; COP 482.24 (c) (2) (viii); JCAHO SIGroup 1/21/04 2:42pm)

E. Health Information Management Department Responsibilities

1. Prior Patient Records – To facilitate continuity of care, providers have access to information from previous care, treatment, and services provided to a patient by the organization. This includes patients' records that are on paper, microfilm/microfiche and in the EMR. (DOH 115.31 (b); DOH 119.24 (b); JCAHO IM 6.60 EOP #1 and EOP #2)

2. Access to Records -The Hospital permits the Medical Staff access to all medical records for bona fide study and research projects. Patient confidentiality must be preserved. (DOH 115.27) The Medical Executive Committee and the Institutional Review Board must approve all such projects before practitioners have access to records for this purpose. Subject to the discretion of the Vice President, Medical Affairs, HIM will permit former members of the Medical Staff access to information from the medical records of their patients. This will include all periods during which they attended such patients in the Hospital.

3. Filing Records - HIM will not permanently file a medical record until (1) the responsible practitioner completes it, or (2) Medical Records Committee orders filing it. For specifics see Section I.

F. Ownership of the Medical Record

1. Ownership - The medical record is the property of The Waynesboro Hospital who will maintain it for the benefit of the patient, Medical Staff, and the Hospital. (DOH 115.28)

2. Removal – No one will remove medical records from the hospital's jurisdiction and safekeeping, except according to a properly executed court order, Subpoena duces tecum, or Administrative approval. Unauthorized removal of medical records from the Hospital is grounds for corrective action according to the MSBRR. JCAHO IM 2.20 EOP #6; DOH 115.28)

3. Release of Information - Without the written consent of the patient, the Hospital requires a valid court order or a valid subpoena for release of medical record information to persons not otherwise permitted to receive this information. (JCAHO IM 2.20; DOH 115.27) See on-line HIPAA Privacy Policies and Procedures.

G. Physician Incomplete Notification (DOH 115.34 61; DOH 107.12 12)

A. POLICY:

The Medical Staff can access a list of how many incomplete medical records that they have at any point in time by using the HIM Record List icon or the List By Doctor And Reason icon on their Meditech Physician Desktop. Health Information Management (HIM) will notify the Medical Staff in writing every Tuesday of the number of incomplete records available. The only exception to the weekly Tuesday notification schedule is if a holiday falls on a Tuesday. In this event, when notification is done the week before the holiday, the suspension date is the following Wednesday (i.e., the day after the holiday.) The incomplete notification day for that week is only Wednesday.

B. PURPOSE:

To consistently notify the Medical Staff of the number of incomplete records available to assure compliance with timely record completion.

C. PERSONNEL RESPONSIBLE:

1. HIM Manager

2. Any other HIM staff involved in, or assigned, this process.

D. PROCEDURE:

1. Incomplete Notification:

A. Every Tuesday morning HIM will run an incomplete report from the computerized chart deficiency system.

B. By noon each Tuesday, give the completed incomplete notification letters to the HIM Manager, or designee for review.

C. Call all physicians that have records that are 24 days or older. (These records would cause the physician to be suspended the following Tuesday if they were not completed) Notate on the letter the time the call was placed to the physician’s office and to whom HIM relayed the message, if unable to contact the physician personally. A call to the physician's office is sufficient for these notification purposes.

D. When all of the appropriate calls have been placed HIM personnel will distribute the originals in a closed, sealed envelope via the physician's mail slots.

E. Making the Telephone Calls for incomplete notification for records that are 24 days or older (records that would cause the physician to be suspended if not completed by the following week): Contact each physician's office that is eligible for incomplete notification in the following manner:

a. Identify yourself.

b. Ask to leave a message for the appropriate physician.

c. Inform them the number of incomplete records that the particular physician has to complete and that the cut off time for completion of these records is the following Tuesday at 9:00 A.M. ** The only exception to this is if that Tuesday is a holiday the suspension day will be the following Wednesday at 9:00 A.M. That week’s delinquent notification will take place Wednesday instead of Tuesday.

d. Ask the name of the person. Then fill out the incomplete notification letter listing the time and name of the person with whom the message was left.

H. Physician Suspension Notification

A. POLICY

1. HIM will notify the Medical Staff members via telephone and in writing every Tuesday of their suspension status, if necessary. Subsequently, if the physician becomes suspended, and remains on suspension for two (2) consecutive weeks, this will be considered a voluntary resignation and termination from the Medical Staff.

2. To consistently notify the Medical Staff of their suspension status and to maintain timely completion of medical records as outlined in the Medical Staff Bylaws, Conditions of Participation, JCAHO standards and Pennsylvania State Health regulations. Timely documentation and completion of records assure complete, timely information that improves the quality of our records.

B. PERSONNEL RESPONSIBLE:

1. HIM Manager

2. Any HIM Staff involved in this process

C. PROCEDURE:

1. Procedure for Suspension:

a. Every Tuesday, verify which physicians did not complete their delinquent records by 9 A.M. -- only the delinquent records that HIM notified them of on the previous Tuesday.

b. Call the physicians who did not complete their delinquent records. Remind them that as of 9:00 A.M. they are on the suspension list due to failure to complete their delinquent records. Document the time that HIM notified the physician’s office and who received the message on the back of the initial delinquent notification letter.

c. At 9:00 A.M., determine if any physicians have not come in and completed their delinquent records. If yes, then send out the suspension letter. Distribute the Suspension letter to the following areas:

1. Admitting/Registration (hand deliver)

2. Emergency Room (hand deliver)

3. Surgical Services/Operating Room (hand deliver)

4. President, Medical Staff

5. Each Suspended Physician's Department Chair

6. Chair, Medical Record Committee

7. Each Physician on Suspension

8. HIM Manager

9. HIM Director

10. Vice President, COO

11. Vice President, Medical Affairs

** The Chart Room retains the original, where HIM documents the date and time that the Medical Staff removed the physician from suspension. The original is then kept in a file afterward for reference and reporting purposes.

2. Procedure for Removing a Physician from Suspension:

A. The HIM staff (coding/clerical/supervisory, etc.) will verify that the physician who is on suspension has completed the delinquent records.

B. HIM notifies the following departments/areas via the telephone/email to remove a physician from suspension:

a. Admitting/Registration

b. Emergency Room (charge nurse on duty)

c. Surgical Service/Operating Room

d. The individual who removes the physician from suspension will document the following on the original suspension letter, the date and time that HIM reinstated the physician’s admitting privileges and maintain the original letter on file for future reference and statistical collection.

3. If a physician Remains on Suspension for More Than One Week

A. The HIM Manager or Incomplete Chart Room personnel will notify the Director of HIM and Medical Staff Services of any physician(s) that have been on suspension for one week. HIM will also document this on a suspension letter in parentheses () after the physician’s name.

B. If that physician has not completed their records by the middle of that week (Wednesday), then the Manager, or designee, will contact the Chair of the Medical Records Committee and the Department Chair for that physician(s), to notify them that a physician is approaching the automatic resignation point. Automatic resignation will be effective at Wednesday 9:00 A.M., two (2) consecutive weeks following the original suspension date. The President will send a letter of notification informing the physician of this, CEO of the Hospital.

4. Reappointment Process- Any physician who has their privileges terminated, will go through the full Medical Staff application process. They will also have to pay any necessary application fees at the prevailing rate. During the application process, the Medical Staff will grant no temporary privileges to the physician.

5. Restrictions that Apply to Physicians on Suspension—The Medical Staff restricts any physician who has been placed on “Suspension” from the following:

A. Serving on the ECU backup list. The physician must provide alternate coverage.

B. Practitioners will transfer no in-house patients to the suspended physician.

C. The physician will not provide any care or services (i.e., surgery, consultations) to any patient admitted after the above date.

HIM will report violations of the above restrictions immediately to the Medical Record Committee for further action.

H. Chronic Offender Status

A. POLICY: Health Information Management (HIM) will notify the Medical Staff member via telephone and in writing every Tuesday of his or her suspension status, if necessary. If the physician becomes suspended and remains on suspension for two (2) consecutive weeks, this is a voluntary resignation and termination from the Medical Staff. If a physician has been placed on suspension six (6) or more times in a 12-month period, HIM will classify them as a Chronic Offender. HIM then refers Chronic Offenders to the Medical Executive Committee (MEC) for review and corrective action.

B. PURPOSE:

1. To consistently notify the Medical Staff members of their suspension status.

2. To maintain timely completion of medical records as outlined in the MSBRR, JCAHO standards and Pennsylvania State Health regulations. (Timely documentation and completion of records assure complete, timely information that improves the quality of medical records.)

C. PERSONNEL RESPONSIBLE:

1. HIM Manager or

2. Any HIM Staff involved in this process.

D. PROCEDURE:

1. Suspension List Review:

a. Each week, the HIM Manager will review the suspension list and log the occurrences of each physician.

b. An occurrence of suspension will be calculated as the incident of being placed on suspension and ultimately removed from the suspension list, not the number of weeks that a physician is on the suspension list.

c. When a physician is suspended for the fifth time during any twelve-month period, a letter reminding the physician of potential chronic offender status will accompany the suspension notice. This will serve as an initial warning of potential chronic offender classification should further suspension occur.

d. If a physician has been placed on suspension for the sixth time during any twelve-month period, this will be forwarded to the Medical Executive Committee for review and action as necessary.

2. Review of delinquent operative progress notes and history and physicals:

a. On a monthly basis, the HIM Manager will run reports to determine the number of delinquent operative progress notes and history and physical reports.

i. Operative progress notes must be written immediately after surgery before the patient gets transferred from one level of care to the next level of care. See Section 8b for the required content elements.

ii. Delinquent H&P’s will be those H&P’s that are either hand written or dictated greater than 24 hours after admission.

b. The reports are reviewed and verified that they are actually delinquent.

c. Delinquent report notification memos are prepared and sent to any member with two or more operative progress notes that are either delinquent or have missing content or two or more H&P’s that are delinquent for one month.

d. When a physician is sent six memos in any twelve-month period, this will be processed as a chronic offender.

3. Notification:

a. The HIM Manager will notify via telephone Medical Staff Services, the President of the Medical Staff, the Department Chair of the Chronic Offender, and the President/CEO.

b. The President of the Medical Staff will send a registered letter to the Chronic Offender, with a copy of this letter placed in the physician's quality assessment file. The Medical Staff President will present the name of the Chronic Offender at the next regularly scheduled meeting of MEC. The letter of notification will specify that if the Chronic Offender is placed on suspension one additional time during the next twelve months, he or she will appear in person before MEC to explain his or her continued failure to complete medical records within the established time frames.

c. Termination of Chronic Offender Status: If a chronic offender does not get placed on suspension and/or does not receive a delinquent report notification memo for one year after being designated a chronic offender, Medical Executive Committee will remove the said physician from chronic offender status.

I. Filing of Incomplete Medical Records

A. Policy: Medical Records Committee may approve the filing of an incomplete medical record under the following guidelines:

The physician is deceased.

The physician is unable due to health or other factors to complete his or her medical records.

The hospital has permanently revoked or suspended the physician's privileges.

The Health Information Management department and administration have taken all reasonable measures to contact the responsible physician to have the records completed.

Procedure:

The Manager of Health Information Management will provide the Medical Records Committee with a list of incomplete medical records for the particular physician. Included on the list will be the patient name, medical record number and a notation of what is incomplete within each patient's medical record.

When the Medical Records Committee approves the filing of the incomplete medical records, the Manager of Health information Management will have the approval statements appropriately filled out.

The Chair of the Medical Records Committee and the Manager of Health Information Management will sign each statement.

Health Information Management will file each statement within each individual medical record, behind the face sheet of the visit to which the statement corresponds.

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[1] Patients undergoing surgery must have an H&P on the chart prior to the surgery, as further provided in these regulations.

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