| A | B |
|---|
| ADT system | A compuer system that records hospital admissions, discharges, and transfers |
| Analysis | Reviewing the medical record to determine that all required documentation is present, including signatures and reports |
| Attending physician | The physician responsible for the total care of the patient throughout hospitalization |
| Deficiency slip | A document completed for each physician identifying missing or unsigned documentation |
| Interface | A computer program that translates the languages of different computer programs so they can communicate with each other |
| NCR | A form that makes duplicates without carbon paper |
| Physician privileges | Those services that a physician is permitted by the medical staff to perform in a healthcare facility. Examples:admitting a patient, consulting, and performing surgury |
| Suspension | Temporary restrictions of a physician's privileges as a penalty for having delinquent medical records |
| Complete record | A record containing all required documentation and authentications |
| Delinquent record | A record that remains incomplete longer than the time allowed by medical staff bylaws, rules and regulations |
| Doctor's box | A method of filing incomplete records by physician rather than by medical record number |
| JCAHO accredidation | Three-year approval given when a hospital meets the standards for quality health care |
| Suspension list | A list of all physicians whose privileges are currently restricted because of delinquent medical records |
| These issues take place before suspension letter is sent to a physician with delinquent records | unsigned records are at least 21 days old;physician's office is reminded that physician will be suspended the following day if records are not complete |
| medical recort is considered complete | all test results are in record, all reports have been dictated, and all documentation is authenticated |
| timeframe for medical record analysis | 2 to 3 days after discharge |
| first things the analyzer does with the medical record | goes through page by page to check for omissions in documentation or missing signatures;assures each page has patient's name, medical record #, and date on which documentation was made. (reason: if a piece accidentally removed, reassembly is correct) |
| time-frame for H & P | w/i 24 hrs of patient's admission, written by admitting physician. Also, must be done PRIOR to surgury |
| interim H & P | only updated physical exam and any changes declared, if patient is readmitted w/i 30 days with same diagnosis |
| short H & P | for outpatient procedures, some hospitals allow a short H & P equivalent to a checkoff sheet for basic PE with added reason for procedure.Requirements vary by hospital |
| consultation reports | document that the consultant has reviewed the medical record and has examined the patient. |
| analysis of consultation report | check physician's orders to see consultations were ordered. Must have a report for each consultation (check progress notesconsultant may have written report on progress note form) |
| timeframe of operative or procedure reports | written or dictated immediately after surgury |
| stuff included in an operative report | names of surgeon and assistant surgeon, |
| items in a description of a procedure | estimated blood loss, any blood or fluids given, drains and tubes placed, patient's condition at the end of procedure |
| If delay in transcription of operative report, surgeon must do these things: | document briefly in progress notes: pre and post operative diagnoses, procedure performed, any specimens removed,other info. to care for patient |
| To insure physicians complete key elements in progress notes | Some hospitals use rubber stamp or preprinted progress note form |
| time element for discharge summary | written or dictated at the time of discharge from hospital (while events are clear in doc.'s mind) |
| These groups determine whom the attending physician is(that should dictate the discharge summary) | individual physicians in hospital, medical staff rules and regs.,HIM management policies and procedures |
| timeframe for physician orders to be signed | 24 to 48 hrs by the physician when order is taken by nurse |
| items to be checked for on a progress note | physician's signature, that an admitting progress note has been written by the admitting physician, and SOME DOCUMENTATION OF TREATMENT GIVEN |
| written requirements of the anesthesiologist | both pre- and post anesthesia notes must be written and dated. The POSTanesthesia note must be written w/i 24 hrs. following discharge from recovery room, per JCAHO |
| items to be checked from nursing | admission database signed by RN, discharge status note (documents date and time of discharge, patient's condition at discharge, to where patient was discharged. Also, medication administration records are checked for nurses' signatures on all shifts, whether meds. were given or not |
| preprinted deficiency slip | normally used when conducting analysis;when ommission in documentation is found, physician must either complete or sign a report or order. (Also indicate on d.s. the patient's name, discharge date, analysis date and physician's nameis found |
| computerized deficiency slip | enter into computer the patient's MRN, discharge date, name, analysis date, physician's names, and deficiencies. If there is an interface with ADT, patient info. and dates will automatically go to deficiency system |
| manual deficiency slip | is usually an original w/one NCR copy.Original goes into MR, and copy is filed by physician name |
| types of privileges temporarily suspended until medical records are complete | admitting, clinical and surgical |
| 3 different persons who may sign the suspension notification | HIM management director, chief of staff, or hospital administrator |
| 4 hospital departments that may receive a suspension letter | admitting, ER, OR ,and nursing units |
| The department responsible to ensure that the suspension list is always current | HIM department |
| terminal diget order | the method most used by hospitals to file records. |
| two incidences of a record having to be filed incomplete into the permanent file | when a physician has moved out of the area, or has died without completing all of his/her recordsRequires medical staff to instruct the HIM director to do so |
| umber of delinquent records accept to retain JCAHO accredidation | may not exceed 1/2 of the average monthly discharges for the hospital |
| If number of delinquent records exceeds 50 % of the average monthly discharges for the previous 12 months | hospital receives Type I accredidation (requires periodic JCAHO submissions) |
| 100 or more percent of the average monthly discharges for the previous 12 months | results in conditional accredidation (requires hospital to develop corrective action plan, submit periodic progress reports, and possibly be resurveyed. |
| if number of delinquent records is > or = to 200 % of the average monthly discharges for the previous 12 months | surveyors will recommend loss of accredidation for hospital |
