Completing Records

Completing Records

E-mail messages are sent weekly to keep you abreast of any incomplete

and/or delinquent medical records. A weekly summary report of incomplete and/or delinquent records is also provided to the Medical staff leadership.

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 RESPONSIBILITY AND RULES

A.Attending of Record: The attending physician includes all Physicians, Dentists and Oral surgeons who are the attending of record for a patient. In the case where a patient is being seen in an allied health professional’s office, e.g. PT, nutrition, this person is the provider of record for this visit and responsible for the same documentation requirements.

B.Record Completion Responsibility: No medical staff member is permitted to complete a medical record on a patient unfamiliar to him/her in order to retire a record. Records that are the responsibility of staff members who are deceased or permanently unavailable will be declared complete for filing purpose by the Medical Record Committee. A note indicating the incomplete status and reason for such is filed in the record.

C.Completion of the Medical Records (as defined within each section of this medical record documentation policy): Completion is the responsibility of the attending physician. Housestaff/fellows/PAs/NPs/Nursing and other Allied Health providers may make entries into the record but the attending is responsible for ensuring the record is complete.

D.General Documentation Rules

Write, print or imprint the patient name and medical record number on the back and front of every page.
For electronic notes: sign/authenticate/ finalize notes using the author’s electronic signature key.
For handwritten/typewritten/computer word entries: Include signature, date and time, and pager or clinical ID# NOTE: Signature must be dated and timed even if date and time appear at the beginning of the entry.
Entries must be permanent and capable of being copied.
Use black or dark blue ink/ball-point... Note photocopying eliminates the difference in ink color. Never use pencil,marker or a highlighter pen.
Do not use abbreviations and symbols listed on the BWH “unapproved abbreviations list” located on-line:
The use of signature stamps is not permitted. See BWH Signature Stamp Use Policy:
Authenticate by signing or entering electronic key, all verbal or telephone orders within 24 hours (unless otherwise specified in a hospital policy).

E.How to Make Corrections (Amendments)

Paper medical record/flowsheet entry: draw a line through it, label it “error” initial, date and time it and write the new entry. NEVER use whiteout or try to obliterate an entry.
Computer order entry: enter a general care order and describe the error or discontinue the order in order entry. If the error is in a signed discharge order or an Auto Discharge Order, you must call the Help Desk and work with the appropriate programming team to make the changes.
Computer Note errors: LMR Note correction/changes can be made before signature via preliminary notes. If made after a note is signed the note will be automatically labeled as “amendment” with the date/time of amendment. A note addendum may be made to add information to a note. The LMR error note functionality includes the ability to retract a note due to incorrect patient, incorrect date, patient cancel/no show or “other”. Retracted notes are kept behind a special retracted tab within the Longitudinal Medical Record (LMR). Note correction/changes in other systems such as BICS must be made via an addendum once the note is signed.

F.Teaching Attending Documentation: BWH adheres to the guidelines set forth by the Centers for Medicare and Medicaid Services (CMS) found at CMS’s Internet Only Manual (IOM); Medicare Claims Processing 100-04 Chapter 12. To meet the documentation requirements of the Medicare Teaching Physician Rule, the physical presence and involvement of the teaching physician during the key portion of each service involving a resident must be clearly documented by the Teaching Attending. Specifics can be found in the Appendix 1.

Documents / Timeframe / Sanction
Admission Note / History & Physical / Within 24 hours of admission. Must be completed no more than 30 days before or within 24 hours after admission. The report must be placed in the patient’s inpatient medical record within 24 hours after admission. An updated medical record entry documenting an examination and any changes in the patient’s condition is required when the report is completed before (within 30 days) admission. This updated examination must be completed and documented in the patient’s inpatient medical record within 24 hours of admission or prior to surgery.
Attending of Record Note / Within 24 hours of Admission. This could be acknowledgement and co-signature of Admit Note/H&P or a brief assessment and plan for admission
Brief Op note / Brief written operative note immediately following surgery or procedure and before the patient is transferred to the next level of care.
Dictated Op Note / Dictated and signed within 7 days of the procedure / Suspension, Release of OR time which is greater than 48 hours out from the time of suspension
Progress Notes / The patient’s physician care team must document daily on all patients
Consultation Reports / At the time of observation.
Final Progress note / Immediately at the conclusion of the hospitalization
Newborn Evaluation
Newborn Summary
Labor and Delivery Record (L&D Blue Sheet) / Started immediately following delivery and completed immediately at the conclusion of the hospitalization
Required for all deliveries except in transit or < 20 weeks gestation. Completed and signed by the conclusion of the hospitalization
Discharge Summary (Dictated) / Dictated immediately at the conclusion of the hospitalization.
Discharging Clinician: Delinquent if not dictated within 48 hours. Must be signed within 7 days post-discharge.
Attending of Record: Delinquent if not dictated, reviewed and signed as final within 14 days post discharge.
Any changes by the attending after the resident has signed it, requires an addendum. / No sanctions will be enforced at the hospital level until Fall, 2010 when a new discharge documentation module will be released.
Discharge Order / Auto Discharge Summary / Immediately at the conclusion of the hospitalization
Death Note Dictation / In the event of an inpatient death, a dictation is required. This must include a brief HPI, hospital course and an objective description of the events leading up to the death (if known). A death pronouncement including the physical parameters observed, the time of death and what family members were informed can be dictated as part of this or can be written in the chart. This should be done within 48 hours of death, signed by the discharging clinician within 7 days and reviewed/edited/signed by the Attending of record within 14 days post-death.
Birth Certificate / 10 days after delivery
Autopsies / When an autopsy is performed, provisional anatomic diagnoses are recorded in the medical record within 48 hours, and the final report is made part of the record within two months, unless exceptions for special studies are established by the medical staff.

* 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.) Inpatient / Same Day Surgery / IVF

/ Emergency Room records are all scanned within the 24-48 hours

after discharge. All scanned documentation are viewable in BICS or

LMR.

* 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 617-582-5209 to obtain a copy of "The Do's of Dictating at BWH".

Computer Access

If you do not have access to these computer systems please call the helpdesk, or if you have questions about record requests call 617 732-6060 for further information.

Medical Record Requests

Photocopies of Protected Health Information

Requests for protected health information, related to hospital based services, should be directed to Health Information Services to ensure that all legal requirements are met. The attached Release of Protected Health Information Authorization form may be completed and forwarded to Health Information Services-Correspondence Section.

For questions regarding the disclosure of protected health information copies, please contact Health Information-Correspondence at 617-732-7471, Monday-Friday, 9:00am to 4:00pm for assistance.

Photocopies of Protected Health Information

For questions regarding the disclosure of protected health information copies, please contact Health Information-Correspondence at 617-732-7471, Monday-Friday, 9:00am to 4:00pm for assistance.