The purpose of this Policy is to set forth the various requirements of the Hospital and the Medical Staff concerning the electronic medical record ( EMR ) in one location for all credentialed providers ("Providers"). This Policy is incorporated in the Medical Staff Bylaws and Rules and Regulations as if stated therein and is to be read in conjunction with the Bylaws and the Rules and Regulations provisions addressing medical records. Section I. EDUCATIONAL TRAINING The purpose of this Section is to set forth the expectations of the Hospital and Medical Staff regarding EMR education and training. It is important that all Providers complete the mandatory training. Without proper EMR training, the passwords will not be made available to users to protect the integrity of the system from untrained users and for the safety of our patients. Providers will not be given their user names and passwords to access the system until they have successfully demonstrated competency by completion of a competency assessment. This Section applies to all Providers who are required to enter information into the EMR unless stated otherwise. During periods of transition, specific goals will be set for Providers to embrace and achieve. The Hospital will provide help and assistance. Some Providers may need more education and assistance than others. The Hospital and Medical Executive Committee (MEC) are willing to provide extra assistance for Providers who may need it, but in the end, each Provider must be an active participant in this learning process. The ultimate goal is that each Provider will demonstrate competency of the functions within the timelines set forth by the Hospital, following recommendation of the Medical Staff. Objective benchmarks will be set to ensure that each Provider is reaching the target. The Hospital will offer several different training times and Providers may come as often as they like to increase comfort level. The Medical Staff expects that each Provider will participate in training. If for some reason a Provider is not available to participate in the training sessions, the Provider needs to let the Medical Staff know immediately the reason for unavailability. MEC expects that all Providers will comply with Hospital policies and procedures that apply to the EMR. Low or no volume Providers who infrequently admit or practice in the Hospital may have alternative training assistance appropriate to their activity. The following categories of Providers are excluded from training: 1. Medical Staff Members who have membership with no privileges 2. Medical Staff Members with Refer and Follow privileges 3. Existing Providers who have had no activity since implementation of EMR 1
The following Providers will be required to complete training and competency assessment prior to providing care at the Hospital: 1. New Providers 2. Existing Providers or locum tenens who anticipate need to provide care, but have not yet completed EMR training In rare cases when care is needed, and the Provider has not completed EMR training and competency assessment, patient safety must take priority. Therefore, staff will work with the Provider to ensure quality care is given to the patient. Staff should contact the Medical Staff Office or Department Chief to report such incidents, and to seek clarification. Department Chiefs (or their designees) have the authority to grant exemptions. The following guidelines in these circumstances include: 1. Provider will hand-write orders which will be entered electronically by nursing staff, and then scanned into the system. 2. Other documentation (i.e., H&P, progress notes, procedure note, etc.) will be dictated by the Provider. Health Information Department (HIM) will print the dictation. 3. Provider will be responsible for signing dictations and returning them to the HIM, to be scanned into the proper EMR. If Provider anticipates providing additional care at CHRH, the Provider is expected to complete EMR training and competency assessment. Providers who do not participate in the education and training may be subject to corrective action unless they can demonstrate competency of the EMR system. The Credentials Committee and MEC will factor progress when making reappointment recommendations. The MEC reserves the right to take the necessary action to encourage all Providers be trained in the EMR system. Section II. ELEMENTS OF VARIOUS COMPONENTS OF EMR The purpose of this Section is to define the requirements of the various components of EMR including general documentation requirements and medical record content. All entries in the EMR must be legible, complete, dated, timed and authenticated either in written or electronic format. Although written document should not occur unless EMR is down, any handwritten documentation must be written in black ink. If documented electronically, black font should be used. Medical records shall be retained in their original or legally reproduced form as required by federal and state law and shall contain sufficient 2
information to meet all accrediting and regulatory requirements. Plain paper facsimile orders, reports, and documents are acceptable for inclusion in the medical record. Emergency Department Documentation 1. Emergency Department records shall document and contain, but not be limited to, the following: a. Identification data b. Time of arrival, means of arrival, time treatment is initiated, and time examined by the Provider, if applicable. c. Pertinent history of illness or injury, description of the illness or injury, and examination, including vital signs. d. To be considered final and not subject to delinquency, the emergency department note shall be complete, dated and signed within twenty-four (24) hours. A. History and Physical (H&P) 1. Requirement The patient shall receive a medical history and physical examination no more than 30 days prior to, or within 24 hours after, registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services. For a medical history and physical examination that was completed within 30 days prior to registration or inpatient admission, an update documenting the review of the history and physical and any changes in the patient s condition must be completed within 24 hours after registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services. 2. Update Requirements The patient must be re-examined documenting any necessary changes. The history must be reviewed documenting any necessary changes. At a minimum, the verbiage must include The history and physical was reviewed, the patient was re-examined and any necessary changes have been documented. The entry must be authenticated and include signature, date and time of entry. A non-finalized history and physical will not become delinquent until twentyfour (24) hours after transcription is completed. 3. Responsibility of the H&P Provider Nurse practitioner co-signed if NP privileges requires. 3
Provider assistant requires a Provider countersignature. Resident requires attending Provider countersignature. 4. H & P Content a. History; b. Chief Complaint; c. Details of present illness; d. Medications; e. Allergies; f. Relevant past, social and family history; g. Vital Signs; h. Patient General Condition; i. Existing co-morbid conditions; j. Inventory of body systems; k. Physical assessment; l. Statement of impressions/conclusions; m. Statement of course of action planned. 5. Physical Requirements if Planned Procedure Includes a. Topical, Local or Regional Block Assessment of mental status; Examination specific to the procedure proposed to be performed and any comorbid conditions. b. IV Sedation Assessment of mental status; Examination specific to the procedure proposed to be performed and any comorbid conditions; Examination of heart/lungs by auscultation. c. General, Spinal or Epidural Assessment of mental status; Examination specific to the procedure proposed to be performed and any comorbid conditions; Examination of heart/lungs by auscultation; Assessment and written statement about the patient s general health. B. Discharge Summary Requirements 1. Purpose For continuity of care, the goal is to have the discharge summary completed within four (4) days following the patient s discharge. A discharge summary is required on all inpatient and observation accounts whose stay is equal to or 4
more than forty-eight (48) hours. A discharge summary is required on all mother s medical records whose infants have an APGAR score of 5 or below at 5 minutes. A discharge summary is required on all mothers who deliver by C-section. A discharge summary will be completed within fourteen (14) days of discharge. If the patient s stay is less than 48 hours and no procedures were performed, a Short Stay Note will meet the requirements for a discharge summary. Please refer to Short Stay Note Requirements set forth below. For patients leaving the Hospital against medical advice (AMA), the attending Provider should indicate that fact in the discharge summary. No discharge order is needed to be written for AMA patients. 2. Discharge Summary Responsibility a. The discharging Provider or the attending Provider. b. If completed by discharging Allied Health Professional, the AHP must specify if countersignature is required. 3. Discharge Summary Content Discharge summaries will contain the following components: a. Provisional diagnosis or reason for admission; b. Principal and secondary diagnoses; c. Clinical resume; d. Significant findings; e. Procedures performed; f. Treatment rendered; g. Condition of patient at discharge; in the cases of death, the date and preliminary cause of death; and h. Specific instructions given to patient and/or family, including provisions for follow up care. C. Short Stay Note Requirements 1. Requirements For continuity of care, the goal is to complete the short stay note within four (4) days following the patient s discharge. A short stay note shall be required on all inpatient and observation accounts whose stay was less than 48 hours except as in the specific cases as noted above in Discharge Summary Requirements. A short stay note will be documented within fourteen (14) days of discharge. 2. Short Stay Note Responsibility 5
a. Discharging Provider is responsible; b. If the short stay note is not dictated immediately following discharge because another Provider is responsible for the short stay note, the Provider must indicate through an order or progress note whom is responsible for the short stay note. c. Any discharging Allied Health Professional must specify if countersignature requirement exists. 3. Short Stay Note Content a. Reason for admission; b. Condition at discharge; c. Disposition of patient; and d. Discharge instructions, including follow-up care. D. Operative Note Requirements 1. Requirements If a detailed operative note is not documented electronically immediately following surgery or other high risk procedure, a brief operative note/postoperative progress note must be documented in the chart following surgery. A detailed operative or other high risk procedure report must be documented or dictated immediately following surgery. 2. Brief Operative Note/Post-operative Progress Note and Operative Note Responsibility The primary surgeon is responsible for the brief operative note and detailed operative note. In the event that a procedure requires another surgeon, the secondary surgeon must follow same content guidelines that are pertinent to Provider s role in the surgery. 3. Brief Operative Note/Post-Operative Progress Note Content a. Name of primary surgeon and assistants; b. Procedure performed; c. Description of findings; d. Estimated blood loss; e. Specimens removed; f. Postoperative diagnosis/es; and g. Any other pertinent data, including but not limited to, complications. 4. Detailed Operative Note a. Name of primary surgeon and any co-surgeon; b. Name of procedure; 6
c. Description of procedure, techniques, and/or methods; d. Findings of procedure; e. Estimated blood loss; f. Specimens removed; g. Post-operative diagnosis/es; and h. Any other pertinent data, including but not limited to, complications. E. Labor and Delivery Note 1. Requirement A Labor and Delivery Note is required for all newborn and vaginal deliveries. In instances where an infant is admitted to NICU, the note shall be documented prior to the transfer. In all other instances, the note is due immediately after delivery. 2. Labor and Delivery Note Responsibility Delivering Provider is responsible for the note. 3. Labor and Delivery Note Content The note will contain a complete account of the labor and delivery F. Consultations 1. Requirement Consultation documentation is required in all cases where a consultation has been ordered and completed by the consulting provider. A consultation includes review of the medical record and personal examination of the patient unless privileged to provide telemedicine services. Surgical consultation documentation is recorded prior to surgery except for an emergency. Consultations must be documented within twenty-four (24) hours from evaluation of the patient. 2. Consultation Responsibility Consulting provider is responsible to document the consultation. 3. Consultation Content a. Pertinent findings; b. Opinions of the consultant; and c. Recommendations of the consultant. G. Pre Anesthesia Documentation 1. Requirement 7
A pre-anesthesia evaluation must be performed for each patient who receives general, regional or monitored anesthesia prior to the start of anesthesia. 2. Pre-Anesthesia Evaluation Responsibility a. The anesthesiologist; b. A doctor of medicine or osteopathy (other than an anesthesiologist); or c. A dentist, oral surgeon, or podiatrist who is privileged to administer anesthesia. 3. Pre-Anesthesia Evaluation Content Within same day as anesthesia, the Provider will: a. review of the medical history, including anesthesia, drug and allergy history; and b. interview patient, if possible given the patient s condition, and examination of the patient. Within 30 days prior to anesthesia, the Provider will: a. note the anesthesia risk according to established standards of practice (e.g., ASA classification of risk); b. identify potential anesthesia problems, particularly those that may suggest potential complications or contraindications to the planned procedure (e.g., difficult airway, ongoing infection, limited intravascular access); c. gather additional pre-anesthesia data or information, if applicable and as required in accordance with standard practice prior to administering anesthesia (e.g., stress tests, additional specialist consultation); and d. develop the plan for the patient s anesthesia care, including the type of medications for induction, maintenance and post-operative care and discussion with the patient (or patient s representative) of the risks and benefits of the delivery of anesthesia. H. Post Anesthesia Documentation 1. Requirement A post anesthesia evaluation must be completed and documented no later than 48 hours after surgery or a procedure requiring anesthesia services or prior to discharge. The evaluation is required any time general, regional, or monitored anesthesia has been administered to the patient. The calculation of the 48-hour timeframe begins at the point the patient is moved into the designated recovery area. 2. Responsibility of the Post-Anesthesia Evaluation The anesthesiologist; 8
A doctor of medicine or osteopathy (other than an anesthesiologist); or A dentist, oral surgeon, or podiatrist who is privileged to administer anesthesia. 3. Content of Post-Anesthesia Documentation a. Respiratory function, including respiratory rate, airway patency, and oxygen saturation; b. Cardiovascular function, including pulse rate and blood pressure; c. Mental status; d. Temperature; e. Pain; f. Nausea and vomiting; and g. Postoperative hydration. Depending on the specific surgery or procedure performed, additional types of monitoring and assessment may be necessary. I. Dental Records/Oral Surgery Records 1. Requirements The medical record should include a description of the oral cavity as well as a detailed description of the problem by the attending dentist/oral surgeon. 2. The history and physical may be provided by the oral surgeon/dentist if he/she has privileges to perform otherwise must be provided by a Provider Member of the Medical Staff. J. Podiatry Records The history and physical must be provided by a Provider Member of the Medical Staff. The podiatrist should perform the part of the history and physical pertaining to podiatry. K. Progress Notes 1. Requirements a. All patients must have progress notes documented and signed every calendar day. b. In order to be considered final and not subject to delinquency, the progress note must be signed. c. Hospice patients must have progress notes documented on a weekly basis. 2. Content of Progress Notes a. Changes in patient condition; b. Changes in treatment or medication; c. Progress from therapies; 9
d. Results from treatment; and e. Discharge planning as applicable. L. Outpatient Records Outpatient records shall document and contain, but not be limited to, the following: a. Identification data; b. Diagnostic and therapeutic orders; c. Description of treatment given, procedures performed, and documentation of patient response to intervention, if applicable; and d. Results of diagnostic tests and examinations done, if applicable. Section III. AUTHENTICATION OF RECORDS 1. Requirement All entries in the medical record should include signature, time and date. The authentication is a reflection that the entry is complete, accurate and final. Authentication can be verified through electronic signatures or written signatures. Unless stated otherwise herein, all signatures must be completed within fourteen (14) days of discharge. All progress notes must be signed within twenty-four (24) hours to be considered final. 2. Responsibility of the Authentication Only individuals who are authorized to make entries in the medical record as Hospital policy. 3. Content All signatures must contain at minimum the first initial, last name and credential of the Provider, time, and date. Electronic signatures are acceptable in the EMR when the signature is linked to a unique identifier, biometric, password, or other secure key/method issued solely for use by the individual performing the authentication. Signature stamps cannot be used in the medical record. 4. Timing All verbal orders, including per protocol and read back and verify verbal and telephone orders need to be co-signed within forty-eight (48) hours of discharge. Section IV. DEFICIENCY AND SUSPENSION NOTIFICATION 10
The purpose of this Section is to define the Deficiency Notification process and the suspension process for incomplete charts. It is the policy of the Hospital to ensure patient safety through the continuity of care and holding those required to make certain entries accountable to the completion of the medical record. Providers will receive notification if their entries are deficient. In order to facilitate continuity of care, better quality review, and timely billing, Providers are required to record the patient s discharge diagnosis at the time of discharge. Any information necessary to complete the coding process must be provided within seven (7) days of request or will be considered delinquent this includes operative notes, discharge summaries, history and physicals, consultations, and outstanding queries. The Table below references operative notes, discharge summaries, history and physicals, and consultation requirements. Days after Notifications Consequences required timeframe 7 HIM sends letter Must be provided within seven (7) days of request or will be considered delinquent, and failure to complete will operate as an automatic suspension of the ability to exercise privileges during any new patient encounter which includes any new admission, consult, or order. However, the Provider will be allowed to continue to exercise privileges to complete any inpatient care started or consults 10 HIM sends letter and Medical Staff Office contacts Provider requested prior to the suspension. Failure to complete the delinquent record by the following Tuesday (within 10 days) will operate as an automatic suspension of the ability to exercise privileges during any new patient encounter which includes any new admission, consult, or order. However, the Provider will be allowed to continue to exercise privileges to complete any inpatient care started or consults requested prior to the suspension. The Table below references outstanding signatures including, but not limited to signatures, dates, and times of all medical record entries. 11
Days after required Notifications Consequences timeframe 7 HIM sends letter Must be provided within seven (7) days of request or will be considered delinquent, and failure to complete will operate as an automatic suspension of the ability to exercise privileges during any new patient encounter which includes any new admission, consult, or order. However, the Provider will be allowed to continue to exercise privileges to complete any inpatient care started or consults requested prior to the suspension. 14 HIM sends letter Failure to complete the delinquent record by the following Tuesday (within 17 days) will operate as an automatic suspension of the ability to exercise privileges during any new patient encounter which includes any new admission, consult, or order. However, the Provider will be allowed to continue to exercise privileges to complete any inpatient care started or consults requested prior to the 17 HIM sends letter and Medical Staff Office contacts Provider suspension. Failure to complete the delinquent record by the following Tuesday (within 17 days) will operate as an automatic suspension of the ability to exercise privileges during any new patient encounter which includes any new admission, consult, or order. However, the Provider will be allowed to continue to exercise privileges to complete any inpatient care started or consults requested prior to the suspension. Completion of those components of the medical record required to be entered and finalized in a defined period of time as set forth in the Bylaws, Rules and Regulations and Policies will be monitored. When warranted, any Provider who has a pattern of not complying with these specific time frames will be referred to the Medical Executive Committee. The suspension will be lifted once all delinquent records are complete. Such suspension does not give rise to fair hearing or appeal rights. 12
Section V. CONCURRENT DOCUMENTATION REVIEW/QUERY RESPONSES The purpose of this Section is to define parameters for clarifying Provider documentation whenever there is conflicting, ambiguous, or incomplete information in the medical record regarding any significant condition or procedure. Any Provider, including on-call Providers or partners for the Provider for the day, receiving a query from the Clinical Documentation Improvement RN will be expected to clarify the record for that Provider in his/her absence. Responses to concurrent queries from the Clinical Documentation Improvement RN are to be made in the medical record prior to discharge. Section VI. USE OF COPY/PASTE AND COPY FORWARD FUNCTIONALITY FOR PROVIDER DOCUMENTATION IN EPIC The purpose of this Section is to provide guidance for the safe, proper and effective use of the copy/paste and copy forward functionality in the EMR. It is intended to align the use of this documentation assist functionality with the Community Health Network precepts of high quality and safe patient care, integrity and accuracy of the health record and assure compliance with governmental, regulatory, and industry standards. This Section addresses acceptable copy/paste, copy forward practices, acceptable uses, including limitations on use; the identification of origin and author of copied information; and sanctions for violating copy/paste policy. 1. Providers documenting in the EMR through use of copy/paste or copy forward functionality must reference (or link to) the original source of the information, including its author, date, and time of entry. Providers are responsible for the total content and medical necessity of their documentation, whether that content is original, copied and pasted, or copied forward. Copy forward can only be used within the same patient record. Information from one patient's medical record cannot be copied into another patient's medical record. Providers may not copy/paste images, including scanned images, photographs, or tables into the EMR or into transcribed reports as these could create storage, printing, release, and readability issues. 2. Any entry into the patient medical record should be an accurate representation of the author's actual work product pertaining to that specific patient encounter. Accordingly, Providers are expected to make original entries into the record or review and appropriately amend any content of an entry that is copied and pasted or copy forwarded. The practice of a Provider copying and pasting the Provider s own previous note into a subsequent encounter's note without thoughtful review, amendment 13
and source referencing to reflect the actual work done by the Provider during the care encounter is strongly discouraged. 3. Providers are accountable for compliant use of documentation assist tools. It is preferred that Providers use a Smart Link to pull lab data, pathology reports, or radiology reports into a note rather than copying and pasting this data or reports into their note. Data copied and pasted into the EMR from sources outside of the EMR may be incompatible and as such may not display as in the original source. Such data may be impossible to print or appear distorted and illegible when printed. This includes multiple file formats such as word processing and spreadsheets. Forms created using word processing, spreadsheets, or other software programs that may include special formatting templates such as checkboxes or tables will not view or print properly when copied and pasted into the EMR. Paper documents from sources outside of the EMR will be scanned into the EMR. For most inpatient areas, the paper documents will be kept in the hard chart and scanned post discharge by HIM. 4. The Medical Staff Office, in coordination with HIM, will monitor compliance to this policy. Approved by the Medical Staff Executive Committee of Community Howard Regional Health October 17, 2017. Approved by the Board of Directors of Community Howard Regional Health November 24, 2017. I\11520553.11 14