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)