Patient Age Group: ( ) N/A (X) All Ages ( ) Newborns ( ) Pediatric ( ) Adult

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1 Title: Documentation of Clinical Activities by UNMH Medical Staff and House Staff Applies To: UNM Hospitals Responsible Department: Office of Clinical Affairs Updated: 05/2016 Policy Patient Age Group: ( ) N/A (X) All Ages ( ) Newborns ( ) Pediatric ( ) Adult DESCRIPTION The purpose of this policy is to ensure that UNMH Medical Staff and House Staff documentation of clinical activities supports and promotes: 1. high-quality clinical care; 2. patient safety and quality improvement; 3. accurate billing for provided services; 4. compliance with regulatory requirements such as Medicare conditions of participation, Joint Commission standards, LCME and ACGME requirements, and state and federal law. DETAILED POLICY STATEMENT 1. General Documentation Principles a. Medical Staff and House Staff shall chart legibly and completely, and shall authenticate each entry by signature, date, and time. All orders shall be authenticated by the ordering Medical Staff or House Staff by signature, date, and time. b. Any addenda to previously recorded entries shall be made under a separate entry, and shall be authenticated by signature, date, and time the addendum was made. c. Documentation of routine inpatient clinical encounters shall be completed in a timely manner, preferably immediately following the provision of care, but no later than 24 hours after the inpatient clinical encounter. This includes completion of both the dictated or written clinical entry and any relevant billing. d. Documentation of routine outpatient clinical encounters shall be completed in a timely manner, preferably immediately following the provision of care, but no later than 48 hours after the outpatient clinical encounter. This includes completion of both the dictated or written clinical entry and any relevant billing. e. Clinical documentation of an inpatient encounter shall contain information to justify the patient s admission, continued hospitalization, treatment, and diagnosis; and shall document the patient's progress and response to treatment. f. Attending Physicians and other Medical Staff shall document their physical presence during the key portion of a service provided by House Staff in accordance with regulatory and billing requirements. g. Documentation of clinical encounters must support the billing of clinical encounters submitted. h. Documentation of clinical activities provided more than 30-days prior is discouraged and requires notification of the Service Chief. 2. Documentation of Medical History & Physical Examination (H&P) 1 a. The minimal contents of an admitting inpatient H&P shall be: i. those elements of the H&P that are immediately pertinent to the chief complaint or presenting problem; 1 During an October 2008 Joint Commission survey, a surveyor asked if this policy requires that an H&P be a component of every outpatient visit or note. It does not. Effective Date: 5/19/2016 Page 1 Page 1 of 6

2 ii. the history of present illness; relevant past medical history; medications; and allergies; vital signs and pain assessment (which may he performed by a nurse or other qualified practitioner and reviewed by the Attending Physician); iii. examination of the cardiovascular system, pulmonary system, and abdomen; iv. additional elements of the H&P necessary for the safe and effective treatment of the patient. b. The minimal contents of an outpatient H&P shall be: i. the history of the chief complaint and examination of at least one major organ system relevant to the chief complaint; ii. additional elements of the H&P necessary for the safe and effective treatment of the patient. c. A medical history and physical examination must be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination must be completed and documented by an Attending physician, a resident, an oromaxillofacial surgeon or allied health practitioner (AHP). d. An updated examination of the patient, including any changes in the patient s condition, must be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration. The updated examination of the patient, including any changes in the patient s condition, bust be completed and documented by an Attending physician, a resident, an oromaxillofacial surgeon or allied health practitioner (AHP). e. A timely H&P, delineated above, must be present in the medical record of every patient prior to a surgery or an invasive procedure, except in emergencies. f. The Attending Physician may delegate all or part of the H&P to other qualified practitioners, but the Attending Physician must review and sign and Admission H&P, and assumes full responsibility for these delegated activities. g. A CNM with admitting privileges does not require Attending review and signature of documentation. 3. Inpatient Progress Notes a. At University Hospital, a progress note shall be entered on the chart by the assigned House Staff member or Allied Health Professional at least daily. b. On all UNMH inpatient services, progress notes shall be entered on the chart by an Attending Physician or CNM with admitting privileges at least daily. c. More frequent notes may be indicated by the patient s clinical condition. d. Under unusual circumstances, less frequent notes may be justified. Lesser frequency of notes shall be approved in writing by the Attending Physician s Department Chair. 4. Inpatient and Emergency Department Consultation Notes a. At University Hospital, a complete routine consultation note shall be entered in the electronic medical record within 24 hours of the consultation. Summary recommendations should be communicated the same calendar day to the treating medical team upon completion of the consultation. b. Urgent or Emergent inpatient consultations, and all Emergency Department consultations, require documentation of summary recommendations available in the electronic medical record immediately following the consultation but no later than 6 Effective Date: 5/19/2016 Page 2

3 hours after the consultation. This may precede the complete written or dictated consultation note. 5. Discharge Summaries and Abbreviated Hospital Summaries a. Discharge summaries shall be dictated or written within 24 hours after discharge b. A discharge summary is required for all discharges following inpatient stays, except for normal newborns that stay for maternal reasons. For normal newborns that stay for maternal reasons a final progress note may be written in lieu of a discharge summary; the final progress note shall be identified as being in lieu of a discharge summary. 6. Operative and Procedural Reports a. All operative and procedural reports shall be written or dictated immediately after the surgery or invasive procedure and shall be available on the chart within twenty-four hours. b. In most clinical circumstances, a detailed and complete operative or procedural note cannot be made immediately available for access in the Electronic Medical Record. Therefore, a provider must enter a brief operative or procedural progress note into the Electronic Medical Record prior to the time the patient is transitioned to the next level of care (see definition). This brief operative or procedural progress note must contain at a minimum: i. the name (s) of the primary surgeon(s) or provider(s) and his/her assistants, preoperative or pre-procedural diagnosis, the procedure(s) performed, a description of key procedural or operative findings, estimated blood loss, specimens removed, and post-operative or post-procedural diagnosis. c. All operative and procedural reports written or dictated by House Staff shall be reviewed for accuracy and cosigned by the supervising Medical Staff as soon as is practicable. d. Prior to surgery or procedures (except in emergencies), oral surgeons and dentists must record evidence of a thorough review of the oral cavity to include a detailed description of the dental problem, oral examination and pre-operative diagnosis. Operative reports should include statements regarding technique, findings, and the specific number of teeth and/or fragments. 7. Use of a Signature Stamp as an Official Signature a. UNMH does not allow the use of a signature stamp as an official signature for patient medical records. 8. Medical Records Completions and Delinquencies a. The Attending Physician will certify the quality and accuracy of the medical record's content. This record will include (when applicable): identifying data, complaint, history and physical examination, special reports (consultations, clinical laboratory, imaging, diagnostics), provisional diagnosis, medical or surgical treatment, operative report, pathological findings, progress notes, evidence of appropriate informed consent, final diagnosis, condition on discharge, instructions on physical activity, diet restriction, follow-up plan, medication list, required signatures and co-signatures, and autopsy (when applicable). b. A medical record is considered to be complete when all elements have been addressed and a signed discharge summary or abbreviated hospital summary is present. Any medical record not completed within fourteen (14) days of discharge of the patient, Effective Date: 5/19/2016 Page 3

4 and without unusual extenuating circumstances that would preclude completion of the medical record, is defined as a delinquent medical record. c. A Medical Staff member with more than twenty-five (25) delinquent medical records in the monthly Health Information Management Department ( HIM ) report shall be notified by HIM in writing and by , with a copy to the Medical Staff member's Service Chief, of the delinquencies. The Medical Staff member shall have one week from the date of notification to contact HIM to review the validity of the assigned delinquencies and to rectify the valid delinquencies. If a Medical Staff member fails to contact HIM within one week of the date of notification, his/her Service Chief and hospital supervisor, if employed by UNM Hospital, shall be notified and the Service Chief or supervisor shall notify the Medical Staff member that, because of the patient safety and continuity of care issues related to medical records delinquencies, no further annual or professional leave shall be authorized until the Medical Staff member has contacted HIM to review the validity of the assigned delinquencies and has rectified the valid delinquencies. d. A Medical Staff member with more than thirty-five (35) delinquent medical records in the monthly HIM report shall be notified by HIM in writing and by , with a copy to the Medical Staff member's Service Chief and hospital supervisor, of the delinquencies. The Service Chief and/or supervisor shall notify the Medical Staff member that, because of the patient safety and continuity of care issues related to medical records delinquencies, no further annual or professional leave shall be authorized, and no further incentive pay shall be released, until the Medical Staff member has contacted HIM to review the validity of the assigned delinquencies and has rectified the valid delinquencies. If the Medical Staff member has not contacted HIM and rectified the valid delinquencies within three (3) weeks, the Service Chief shall, in accordance with Section (a) of the Bylaws, ask the Associate Dean for Clinical Affairs to issue a written notice to the Medical Staff member warning the member that he/she has fourteen (14) calendar days to comply or administrative suspension may be imposed. e. As per Section (a) of the UNMH Medical Staff Bylaws, Failure to comply with UNMH clinical documentation policies and requirements may result in the administrative suspension of a Medical Staff Member, provided that the suspension must be preceded by a written warning to the Member from the Associate Dean for Clinical Affairs or his/her designate that the Member has fourteen (14) calendar days to comply with UNMH clinical documentation policies and requirements or administrative suspension may be imposed. The Associate Dean for Clinical Affairs or his/her designate will provide the Medical Staff Member and the Medical Staff Member's clinical or associate Department Chair with a copy of the written warning. If the Associate Dean for Clinical Affairs or his/her designate subsequently initiates an administrative suspension, he/she will provide the Medical Staff Member and the Medical Staff Member's clinical or associate Department Chair with immediate written notification of the administrative suspension. The suspension will be in effect for the time specified in the notice of suspension, but may not exceed ten (10) consecutive calendar days. Effective Date: 5/19/2016 Page 4

5 f. As per Section (a) of the UNMH Medical Staff Bylaws, If the Medical Staff Member has more than thirty (30) administrative suspension days in a consecutive twelve (12) month period, that Member shall be deemed to have automatically and voluntarily resigned from the Medical Staff, said resignation to take effect upon acceptance by the Member's Clinical or Associate Department Chair." g. Surgeons with operative reports more than 24 hours delinquent may not perform further elective surgeries until the delinquent operative reports have been dictated or entered into the medical record. APPLICABILITY This policy is applicable to all UNMH Medical Staff members, including Allied Health Professionals, and House Staff members providing clinical care at UNMH. REFERENCES UNMH Medical Staff Bylaws University of New Mexico House Officers and the University Regulation and Benefit Manual UNMHSC Policy, Prohibited Abbreviations UNM GME Policy, Supervision of Physicians and Dentists in Training ( accessed 2/20/12) 42 CFR 482 Medicare Conditions of Participation and subsequent clarifying documents DEFINITIONS 1. Signature A signature is a legible and distinctive mark that identifies a particular individual. For the purposes of this document, examples of acceptable signatures include: a handwritten name (note that it must be legible); a legibly-printed name accompanying a less legible handwritten name; a signature stamp; an individual number accompanying a handwritten name (e.g., pager number, billing number); or an electronic medical record caregiver identification generated from an individual, password-protected login. 2. Attending Physician The attending physician is the Medical Staff member primarily responsible for the care of the patient. 3. Allied Health Professionals (AHP) consists of clinicians whose primary license, certification, or professional degree is as an Advanced Practice Nurses (APN), Clinical Nurse Specialists (CNS), Certified Nurse Practitioners (CNP), Certified Nurse Midwives (CNM), Certified Registered Nurse Anesthetists (CRNA), Physician Assistants-Certified (PA-C), clinician pharmacists (PharmD), Doctors of Oriental Medicine (DOM), or licensed optometrists (OD) and as defined by the UNM Hospital Bylaws 4. HIM University of New Mexico Hospitals Health Information Management Department 5. Invasive Procedure An invasive procedure is a significant clinical procedure which involves puncture or incision of the skin; insertion of an instrument or foreign material into the body; administration of anesthesia; sedation; such procedures may include, but are not limited to surgeries; percutaneous aspirations and biopsies; cardiac and vascular catheterizations; laser procedures; endoscopies; angioplasties; implantations; electroconvulsive therapy; and conscious sedation. Invasive procedures do not include such Effective Date: 5/19/2016 Page 5

6 things as simple venipuncture ( phlebotomy ), routine placement of a Foley catheter, or routine placement of a peripheral IV. 6. UNMH University of New Mexico Hospitals 7. Transition to next level of care The Pre-Op, OR and PACU are considered the same level of care, as the clinical team is essentially intact across these areas. The patient s post-operative note needs to be completed before the patient leaves the PACU, is transitioned to floor orders and modalities of care in the PACU, or in situations where the surgeon personally transfers and accompanies the patient to a critical care area; upon patient arrival to the critical care area. SUMMARY OF CHANGES May Transition to next level of care added RESOURCES/TRAINING Resource/Dept Office of Clinical Affairs (505) Health Information Management (505) Internet/Link DOCUMENT APPROVAL & TRACKING Item Contact Date Approval Owner Associate Dean for Clinical Affairs Committee(s) UNMHSC Medical Executive Committee Y Nursing Officer Sheena Ferguson, MSN, RN, CNS, CCRNr, Chief Nursing Officer Y Medical Officer UNMH Chief Medical Officer Y Official Approver Associate Dean for Clinical Affairs, UNMH Y Official Signature Date: 5/19/2016 Effective Date 5/19/2016 Origination Date 2/2006 Issue Date Clinical Operations P&P Coordinator 2/8/2014, 10/16/14, 11/16/14 ATTACHMENTS None Effective Date: 5/19/2016 Page 6 Page 6 of 6

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