Medical Records
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Transcript of Medical Records
House Staff Orientation
Location: Basement of RockFinancial Counseling
& Medical Records
Hours of operation7 days a week
2 shifts – 7:30 a.m. through 11 p.m.
Main phone number – 2-2044 215-707-2044
Record Access – Imaged medical record, Alpha Imaging
Record Completion – on-line Discharge Summary Dictation Operative Report Dictation
Death Certificates/Gift of Life/Autopsy consent
Documentation
DICTATIONDICTATIONPersonal dictation # to access the systemComplete computer training, receive dictation
system access
How to DictateWithin hospital, dial 5555Outside hospital, dial 1-877-292-5018Follow promptsEnter your dictation #Identify the work type1 Operative Report – TUH2 Discharge Summary –TUHUse the blue dictation card as a guide
Start with:patient name (spell it)medical record #admit & discharge dateinclude Attending by
name At end of dictation a job #
for dictation is provided – enter it into Alpha at the prompt
Required for EVERY operative procedure performed in the Operating Room
Inpatient and outpatient
1. Immediate Post OP form to be filled out immediately following the procedure
2. Full Dictation also required through dictation system
Dictate Immediately after procedure
Complete OP report within 24 hours of procedure
Dictated within 24 hours
after the procedure
• Complete immediately
following procedures
performed in O.R.
before patient moves
to next level of care
• Serves as a
communication tool
while OP report is
being transcribed
• Write DATE and TIME
on everything
• Findings: Be Specific
DO NOT write
“See….”
Required on ALL inpatient admissions
LOS < 4 days use the MIS pathway Complete all items “Pending”-not acceptable
LOS > 5 days requires a dictated Discharge SummaryRefer to BLUE dictation cards
Key Components
•Patient’s name (Spell)•Medical Record / Account Number•Admission/Discharge, Expiration Date•Attending Physician•History of Present Illness•Hospital Course by Problem•Disposition & Discharge Instructions•Dictating Physician (Spell)•Copies: Names (Spell) and Addresses
Key Components
•Patient’s name (Spell)•Medical Record Number•Admission/Discharge, Expiration Date•Attending Physician•History of Present Illness•Hospital Course by Problem•Disposition & Discharge Instructions•Dictating Physician (Spell)•Copies: Names (Spell) and Addresses
MIS Pathway Discharge Summary
State who is responsible for dictating the discharge summary
IN ORDER TO USE MIS PATHWAY, MUST BE ENTERED ON SAME DAY OF DISCHARGE
and related documents overview
Located on all nursing units
Death Certificate blank and sample Gift of Life Consent to Autopsy Form
Medical Examiner protocol
MIS Pathway must be completed
Please note – the decedent cannot be released to the funeral director without the completed paperwork.
State who is dictating the discharge summary
Note a Gift of Life entry
Note whether or not it is a Medical Examiner case
EVERY DEATH must be called into Gift of Life
This is a PA state requirement
Most common error –
must be signed by
the physician
on the
witness line
Authentication is date/time/sign/contact phone #
Write Legibly
Abbreviations list
Verbal orders signed within 24 hours in MIS
Point of Care Scanning & Coding
POC Coding Worksheet POC Coding Worksheet On admissionOn admission
Code on admission for two purposes1. Documentation questions for coding2. CORE measure admission identification
QD (daily) QOD (every other day) U (units) IU (International units) MSO4 (Morphine Sulfate) MGSO4 (Magnesium Sulfate) MS (Morphine sulphate, mental status, etc) ARA-A & ARA-C (Cytarabine) OXY (OXY-IR, Oxycontin, Oxycodone & Oxytocin) MTX (Methotrexate) Medication Dosages: Never Use Terminal Zeros (1.0) Always Use Leading Zeros (0.5)