Resident Orientation Health Information Management Department (HIM)
Authentication Form Authentication form needed in the event you sign any documents on paper. Wake Forest Baptist Medical Center 2
HIM Location & Hours Location: 4 th Floor, South Building Chart Analysis Area Phone: 336-716-3219 After Hours Phone:.336-716-4787 Hours of Operation: Monday-Friday 24/7 Weekends Call on-call supervisor Wake Forest Baptist Medical Center 3
Where are Medical Records Maintained? Most patient documentation can be found in WakeOne (Electronic Health Record- EHR) in various tabs located in individual charts. o Encounters, notes, Meds, Labs, Micro, Imaging, Procedures, Cardiology, Other Orders, Episodes, Letters, Referrals, Media, Misc Reports, Pat Sum Extracts o Scanned documents can be found on the media tab. o Historical documents are located under Historical Documents button above the tabs. This is through On-Base. Paper records filed in Medical Records On Campus Storage Prior to 10/2006 Off Campus locations various clinic locations still have some paper medical records on site. Wake Forest Baptist Medical Center 4
Health Information Management Standards Removing Medical Records from Inpatient Nursing Units or Hospital Premises. Release of Medical Information o Must Follow HIPAA Rules. o Forward to Release of Information Office in the Health Information Management Department. Wake Forest Baptist Medical Center 5
HIM Intranet Site http://intranet.wakehealth.edu/departments/health-information-management/ Wake Forest Baptist Medical Center 6
Dictation **WFBH preference is for providers to type notes but dictation is available. **HIM will provide dictation cards to Residents Wake Forest Baptist Medical Center 7
Dial In Dictation Instructions Dictation Card Wake Forest Baptist Medical Center 8
Partial Dictation Instructions Partial Dictation Instructions Wake Forest Baptist Medical Center 9
Electronic Authentication Performed in WakeOne through the In-Basket Folders Must electronically authenticate all documents you dictate. Electronically sign documents DAILY. Dictated items fall into the Transcription folder in the in-basket, but can also be found in the Hospital Chart Completion folders by patient and note type, as well as My Open Charts for outpatient clinic notes. Unauthenticated documents flow to WakeOne as soon as transcribed before authentication. When authenticated, document will update with any changes. Attending Physicians required to electronically countersign much of what House Officers dictate - - History/Physicals, Operative Reports, Discharge Summaries. Wake Forest Baptist Medical Center 10
Paper Documentation Must be legible Date and Time All Entries Wake Forest Baptist Medical Center 11
Documentation Standards Copy-Paste or Cloning Providers are required to document in compliance with all federal, state, local laws and Medical Staff Rules and Regulations. The writer/author of each document is responsible for all of the content of that document, and must ensure that any material copied into that record accurately reflects the care provided during that episode of care. All copied information from other electronic sources shall be credited to the author. It is appropriate to copy and include information needed to support clinical decision making and the care rendered during a specific episode of care. However, summarization of any records, test results, etc. is strongly encouraged. The copying of information from one patient record to a different patient s records is prohibited except in the circumstance when documentation was entered in error. Cloning of documentation is not allowed. When it is necessary for clinical care, to copy information from the note of one provider to another provider, the Information copied should be referenced to include date, time and author of the original entry. Information copied from a previous note by the same author should include only that information that is unchanged. Copy/paste or copy/carry forward of student notes is prohibited. Copying Teaching Physician attestations from previous notes is prohibited. Wake Forest Baptist Medical Center 12
Documentation Standards (con t) Prohibited Abbreviations Cannot use in any handwritten documentation, computer text entry, or pre-printed forms. Wake Forest Baptist Medical Center 13
Documentation Timelines Responsibilities for documenting and/or completing medical records vary by clinical service. If not told, please Ask!!! History and Physical o Must be completed within 24 hours of admission or prior to surgery. If a H&P has been completed within 30 days of admission, this H&P may be used, but must be updated at the time of admission or prior to surgery. Operative Notes o Dictated report or manually created report required within 24 hours. o Must document brief op note immediately after surgery before transition to next level of service (unless full note is done immediately). In-Patient Progress Notes o Must be completed daily. o Attending must co-sign. Wake Forest Baptist Medical Center 14
Documentation Timelines (con t) Discharge Summary o Complete on Day of Discharge. o Dictate or manually type in WakeOne; preferable type your note. o Be careful to select the correct admission. Clinic Notes o Must be documented by the provider as soon as possible the day of clinic visit, but no later than 24-48 hours. o Method of documentation determined by clinic (options include partial dictation, full dictation, or manually creating). Admission Orders o Signature or countersignature required (within 48 hours) of the inpatient admission order by the certifying physician (the order). Wake Forest Baptist Medical Center 15
Documentation Timelines (con t) Verbal and Inpatient Orders Refer to Provider Physician orders policy: http://ishare.wakehealth.edu/governingpolicy/policies/provider Physician Orders.pdf o The hospital minimizes the use of verbal and telephone orders. Telephone and verbal orders should be accepted only when a prescriber does not have ready access to the electronic health record, e.g., scrubbed in sterile procedure, engaged in a code situation. o Telephone/verbal orders should not be accepted for admission orders, other routine orders or for antineoplastic (chemotherapy) agents. o Signatures/Countersignatures require the signature of the provider, date and time of the signature. The ordering provider should sign all verbal and telephone orders within one week (seven days) of the time the order was given. o Orders written/entered by a medical student, physician assistant student, scribe or Acting Intern will be pended until co-signed electronically by the responsible physician before the order becomes active and the nurse can see the order in the order profile and carry out the order. It is the responsibility of the prescriber to obtain the appropriate signatures. Electronic order entry, including activation of pended orders in WakeOne is not allowed beyond 2 hours following patient discharge. Wake Forest Baptist Medical Center 16
Chart Analysis Key documents for analysis post discharge/visit o History and Physical o Operative Note o Telephone Verbal Orders o Discharge documentation and/or Discharge Summary If above documentation is missing and it is determined you are the responsible physician, a deficiency will be assigned to you. This can be found in your in-basket. Wake Forest Baptist Medical Center 17
Deficiency Reporting All provider documentation is considered delinquent at 7 days. Documentation must be complete within specified timeframes of document type such as H&P complete within 24 hours, clinic notes within 24-49 hours, etc. 7 day reporting Time frame = Sunday Saturday o Routine Reports re sent to Providers/Residency Coordinators Tuesday, Wednesday, Friday Faculty/house staff will have until Monday 2 pm to complete records Final Report Sent Mondays o Chairs will determine which providers will be granted Amnesty or placed on Administrative Duty by 3 pm Monday. o If provider completes charts on Monday, providers should notify Chair/BA and HIM when charts are complete. NOTE: Residents should note if they complete work at the 7 day point, attendings will be held accountable for the deficiency. Wake Forest Baptist Medical Center 18
Deficiency Reporting (con t) Amnesty or Administrative Duty Tuesdays o Department Chair will reassign faculty/house staff to administrative duties until HIM certifies all records are up to date o If granted Amnesty Chairs should indicate Reason for Amnesty Length of time for Amnesty (preferably no longer than 7 days) Providers will be given a timeline for completion Wake Forest Baptist Medical Center 19
Thank you Please call us if you need our assistance Welcome to Wake Forest Baptist Medical Center Wake Forest Baptist Medical Center