|
Business hours
* Chart Control is open 24 hours a day.
* Record Completion is staffed from 7 am - 4 pm, Monday - Saturday.
Note: You may access this area to complete charts anytime through
Chart Control.
* Correspondence is staffed Monday - Friday from 9 am - 4 pm.
* Research, Coding, Processing and Tumor Registry (Located at DFCI
454 Brookline Ave Suite 2) are staffed from 8 am - 4:30 pm, Monday
- Friday.
* Birth Certificates is staffed 7 am - 4:30 pm, Monday - Friday.
Telephone numbers
Birth Certificates 617 732-6108 DRG/Coding 617 732-6029
Chart Control 617 732-6060 Correspondence 617 732-6071
Dictation/Transcription 617 732-7472 Research 617 732-2786
Record Completion/processing 617 732-6119 Tumor Registry 617 632-3227
Completing Records
E-mail messages are sent weekly to keep you abreast of any incomplete
and/or delinquent medical records you may have. A summary report of
these incomplete and/or delinquent records is also provided to the
Chiefs.
You can view your incomplete records online. In order to do this,
enter CI (Clinical Information), R (Medical Record Option) and I (Incomplete
Records). House Officers and fellows who fail to fulfill satisfactorily
their record keeping responsibilities may be subject to disciplinary
action.
Documentation Requirements
| History and physical |
within 24 hours of admission |
| Surgical procedure |
Brief op note written in chart immediately following surgery
followed by dictating immediately after surgery |
| Verbal order |
and authenticate within 24 hours |
| Progress note |
(1) daily on critically ill patients and/or where there is difficulty
in diagnosing or managing the patient
(2) at least every 2 days on all other patients |
| Discharge order form |
before discharge. List all diagnoses, procedures and discharge
medications. Do not use abbreviations. |
Discharge summary/
clinical resume
Death Pronouncement
|
Patients with a length of stay less than 6 midnights do not
require a dictated discharge summary. The Auto Discharge Summary
may be used at the time of discharge. Stays longer than 6 midnights.
Require dictating immediately at the time of discharge.
All deceased patients require a dictated summary. Patients
discharged within 48 hours do not require a dictated summary.
Written in progress notes at time of death. Must include the
date and exact time of death (AM/PM). Must be signed by physician.
|
* Do not abbreviate final diagnosis,
procedures, or orders.
* Use only BWH approved abbreviations.
* Countersign any student workup, progress note and/or orders.
* Write legibly and use only a black
ball-point pen.
* Make a correction by drawing a line through the error and then signing
and dating it.
* Never use liquid paper or try to obliterate
the entry.
* Do not remove records from the nursing unit after a patient is discharged;
Health Information staff will pick up the record the same day for
processing. (The department is open 24 hours a day; you have access
to records any time.)
* Bar codes are computer sensitive and should not be defaced.
Dictating Records
Any telephone may be used for dictating. Instructions are
located on all patient floors, as well as the operating room and Health
Information Services. Note: Call 617
732-7472 to obtain a copy of "The Do's of Dictating at BWH".
Computer Access
If you do not have access to these computer systems, or if you have
questions about record requests call 617 732-6060 for further information.
Medical Record Requests
| one record for inpatient or outpatient care for the same day |
record request option under UTILITIES, select PRIORITY 2 or
3 |
| one-two records to review for patient care |
record request option under UTILITIES, select PRIORITY 4 |
| records for outpatient care for a future date |
master booking system for clinics or the Patient Information
System, select RECORDS IN ADVANCE (48 hour notice required) |
| records for quality improvement review |
Patient Information System, select RECORDS IN ADVANCE, and
specify the date needed |
Photocopies of Records
Any release of medical information including photo-copies must be
coordinated through the Correspondence section. There are legal requirements
that must be met in all cases. Do not attempt to handle such requests,
but refer them to the Correspondence section of Health Information
Services (Medical Record Services).
Medical Record Documentation
It is important that progress notes document the necessity of the
patient's stay in an acute care institution. A progress note to the
effect that the patient is here awaiting placement, without additionally
describing the condition of the patient, will immediately suggest
to a reviewer that this requirement is not being met and will result
in disallowance of third party payments. This can be harmful financially
to the hospital and to the patient, particularly if the writer of
the note is no longer available to help with a rebuttal when the chart
is reviewed.
Note: The medical record is often reviewed
concurrently or retrospectively by outside agencies on behalf of third
party payers, quality assurance groups or other agencies. In many
cases, reimbursement to the hospital will be determined by physicians’
notes or orders in the record.
Discharge Procedures
The medical record remains on the nursing units for one day after
a patient's discharge so that the record is available for completion.
When completing a medical record:
* use black ink for all entries in the
medical record
* limit the use of abbreviations. Abbreviations for diagnoses may
not be used on the facesheet or on the
discharge summary, since these are widely distributed and abbreviations
can be misinterpreted.
* use language that can be read by any third party
* use the following definitions when completing the facesheet:
* Principal diagnosis: The condition determined after study to be
responsible for this admission to the hospital. There can be only
one principal diagnosis.
* Secondary diagnosis/es: All conditions that existed at the time
of admission, that developed subsequently, or that affect the treatment
received and/or the length of stay (complications and/or co-morbidities).
* Principal procedure: The procedure performed for definitive treatment
rather than for diagnostic or exploratory purposes; usually the procedure
most related to the principal diagnosis. There can be only one principal
procedure.
Incomplete Records
A weekly listing of incomplete records is compiled and a notification
letter is mailed to each responsible physician. If a record remains
incomplete for 14 days or more it is considered delinquent. If a physician
has five or more delinquent records s/he will receive a letter warning
the physician that all delinquent records must be completed within
seven days to avoid suspension. If they are not complete by the designated
deadline, all clinical privileges will be suspended.
Each physician is responsible for completing all medical records
before leaving a Service or the hospital. Any questions or
problems regarding incomplete records should be discussed as soon
as possible with the Record Completion staff (617 726-2490).
You should also contact the Record Completion staff immediately
if an incomplete medical record has been assigned to you but
should be completed by another physician or if you are going to be
on vacation.
DICTATING RECORDS
Records not completed on the nursing units or in the Same Day Surgical
Unit are filed in the Physician Dictation and Record Completion Center
within the Health Information Management Department (HIM), Clinics
Basement. The Center is open Monday - Friday, 7 am - 11 pm, Saturday
and Sunday, 7 am - 3:30 pm.
GENERAL GUIDELINES FOR DICTATION
Before starting to dictate the report
* Identify yourself by your full name and Service.
* State if you are dictating for another physician.
* Spell out the patient's full name and state the patient's medical
record (unit) number.
* For operative notes, give the date(s) of surgery, pre- and post-operative
diagnosis/es and the name(s) of all procedures performed.
* For discharge summaries, give the dates of admission and discharge.
Important points
* Spell all proper names and difficult words.
* Indicate paragraphs and punctuation.|
* Operative reports and discharge summaries must be signed.
* Dictating House Officers may receive a copy of all reports dictated,
if requested at time of dictation. Note:
The HIM Department does not mail copies to House Officers. These copies
are kept on file in the Transcription Room for pick-up during staffed
hours (8 am - 5 pm).
* Indicate the date and time you dictated the discharge summary on
the back of the face sheet.
At the end of dictation
State the number of copies required and to whom they are to be sent.
Note: You must state and spell the full
names and addresses of physicians who should receive copies.
Operative Reports and Discharge Summaries
Physicians may dictate operative notes and discharge summaries into
a computerized dictation system from any MGH touch-tone telephone.
Detailed guidelines for dictating discharge summaries are available
in the HIM Transcription Section (617 726-2488).
Each physician is assigned his/her own 5-digit provider number with
which to access the dictation system. This number can be obtained
by calling 617 726-2488.
You may access the dictation system from any MGH touch-tone telephone.
You may also access the dictation system from Dictaphoneâ hard-wired
dictation units. These units are located in key dictation areas of
the hospital, including the Physician Dictation and Record Completion
and in the operating room complex.
Instructions for use of the dictation system are given below, and
are also provided at each station.
1. Call 617 724-3125 and wait for the prompt.
2. Enter your 5-digit physician ID number, then # on the keypad.
3. Enter the 2-digit worktype code (see below), then # on the keypad.
4. Enter the 7-digit medical record number, then # on the keypad.
5. To start to record, press 2 (you will hear a continuous tone that
stops when you begin to dictate).
6. To end the dictation, press 5, then hang up.
Worktypes
* operative report
* sensitive operative report
* discharge summary
* sensitive discharge summary
* discharge summary/post mortem letter format
* sensitive discharge summary/letter
* STAT transfer summary: to be used only when a patient is being transferred
to another healthcare facility
The Record Control Center should be notified as early as possible
that a record will be needed.
Requesting Records for Patient Care
or Administrative Use
To obtain a record for administrative use, the Record Request Slip
must be delivered to the HIM Record Control Center no later than 11:15
am on the day prior to the date the record is needed. Requests for
records needed for patient care purposes on an immediate basis may
be made by calling 617 726-2475 or 617 726-2477.
Requesting Records for Research
Complete a "Research Request Form'' and Record Request slip(s),
available at the Record Control Center. Residents must also obtain
written permission from their clinical directors to use medical records
for research; this should be submitted with the "Research Request
Form". If the research involves patient contact or the review
of highly sensitive patient information, written approval must be
obtained from the Subcommittee on Human Studies.
A maximum of 20 requests will be accepted at one time; these should
be placed in the designated box at the Record Control Center. A three
day notice should be given to have the records pulled. All records
requested for research may be used only in the Doctors' Reading Room
(open 7:30 am - 11 pm, Monday - Friday and 7:30 am - 3:30 pm, Saturday
and Sunday). Records may not be removed and must be reviewed within
two weeks or they will be returned to file.
Note: Physicians with delinquent records
will not be permitted the use of medical records for research purposes
until the delinquent records are complete.
Release of Medical Records
All information in medical records is considered confidential and
should not be discussed with anyone except the patient without appropriate
written authorization. Patient information should not be faxed outside
the institution. Refer all requests for faxed patient information
to HIM at 617 726-2485.
If a current inpatient requests to see a copy of his or her medical
record, refer the patient to his or her attending physician. All other
patient and third party requests for medical records should be directed
to the Correspondence Section of the Health Information Management
Department.
The Correspondence Section is not responsible for completing insurance
disability forms or General Relief/Welfare forms. These forms are
to be completed by the physician.
If you have any questions regarding release of medical records, call
the Correspondence Section at 617 726-2485 and refer to the medical
record policies in the Clinical Policy and Procedure Manual. Correspondence
is open 8 am - 4:30 pm, Monday - Friday.
Returning Records
* Inpatient records: Inpatient charts should not be put in return
boxes or sent through house mail; they should be delivered to Record
Processing, Clinics Basement. All records of recently discharged patients
(inpatients, SDCU and bedded outpatients) should be returned to Record
Processing for analysis, coding and completion.
* Outpatient records: Outpatient records should be returned to the
Record Control Center as soon as possible after their use. Outpatient
records may be returned via the HIM messengers by placing them in
the medical record return boxes, by bringing them to the Record Control
Center in the Clinics Basement, or by calling 726-2474 to request
that records be picked up.
Transferring Records
As records are needed throughout the institution for a variety of
reasons, it is imperative that HIM know the location of all records
at any given time. Users are therefore requested to inform the department
whenever they "lend" a record that is currently in their
possession. This can be done by calling 617 726-2474, or by filling
out a "Record Transfer Slip" and returning it to the Record
Control Center.
UNIT NUMBER SYSTEM
The hospital's medical records are maintained under a unit number
system. Each patient is assigned a permanent hospital number (the
"unit number") upon his/her first visit to MGH. This number
is then used for any subsequent visits to the institution.
Obtaining a unit number
The original unit number is assigned at patient registration areas
(inpatient, outpatient, Emergency Department, health centers, etc.).
To obtain the number of a patient who has been registered, call the
Patient Index Section (617 726-2482) with the patient's name, date
of birth and address. If you are aware that a patient has been assigned
multiple unit numbers notify the Patient Index Section (617 726-2482)
and the records will be combined as soon as possible.
|
Back to Top