The medical record is an essential ingredient for good medical care. The record serves many purposes and proper documentation, chart completion, and respect for the medical record are expected of all residents. The medical record is, and always will be, an important part of your medical career, so the time to develop good habits is now!
You are referred to Physician Orientation to Health Information and Record Management, Shands Hospital, for a full description of medical record documentation and department services. Key highlights are listed below:
- Indicate the patient’s full name and medical record number in the upper right corner of all forms.
- Write your note immediately after treating the patient. The longer you wait, the less you will retain about the patient.
- Be specific.
- Sign, date, and time all entries.
- Do not use abbreviations unless they are listed in the approved abbreviation list published by Health Information and Record Management.
- Abbreviations are not acceptable for diagnoses and are not to be used on informed consent forms.
- Choose your words carefully. The medical record is not the place to vehemently disagree with a policy or a colleague.
- Make alterations carefully, avoid obliterations, or creating the appearance of tampering. Cross off errors with a single line, ensuring the entry is still legible. Date and initial the correction.
- Write in black ink.
- Write neatly so that another healthcare provider can read your entry in the record.
By law, the medical record must be complete within thirty days of a patient’s discharge. In order to accomplish this, all physicians need to complete their medical records while the patient is in house or visit the Physicians’ Workroom minimally once per week. Residents should sign in to document compliance.
Although it varies by service, most residents are responsible for signing their own progress notes, verbal orders, and dictating operative reports and discharge summaries.
Your attention to the completion of medical records is reported biweekly to the Department Chairman, the Chief of Staff, and the Department Representative to Health Information and Record Management. Failure to complete medical records in a timely manner may jeopardize your clinical privileges.
The Physicians’ Workroom is open Sunday through Thursday from 8 a.m. to midnight and on Friday and Saturday from 8 a.m. to 4 p.m. Calling the Workroom (5-3124) two hours before your expected arrival will expedite the retrieval of records. When you enter the Workroom, sign in at the desk so your medical records can be retrieved. When you have completed the records, sign the sheet that lists your pending medical records.
Definition for Reporting Diagnoses and Procedures:
- Principal Diagnosis: The condition established, after study, to be chiefly responsible for the admission of the patient to the hospital.
- Secondary Diagnosis: All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay. Diagnoses that relate to an earlier episode, which have no bearing on the current hospital stay should be excluded.
- Principal Procedure: The procedure that was performed for definitive treatment rather than one performed for diagnostic or exploratory purposes or for management of a complication. If there appear to be two major procedures, the one most related to the principal diagnosis should be selected as the principal procedure.
- Secondary Procedures: These procedures are listed in order of significance using the following criteria:
- Surgical in nature
- Carries a procedural risk
- Carries an anesthetic risk
- Requires specialized training
Coding Guidelines for Reporting Other (Additional) Diagnoses
General Rule: For reporting purposes, the definition of “other diagnoses” is interpreted as additional conditions that affect patient care by requiring:
- Clinical evaluation
- Therapeutic treatment
- Diagnostic procedures, or
- Extended length of hospital stay, or
- Increased nursing care and/or monitoring
Transcription is staffed 24 hours a day except for Saturday and Sunday. “STAT” transcription is available for patient transfer during non-business hours and on holidays by calling 5-0131. Written instructions for using the dictation system are provided by Health Information and Record Management.
Discharge summaries should be dictated on the day of discharge by the first, second or third-year resident directly responsible for the case. Timely dictation is an essential part of training since pediatric privileges at future hospitals will be curtailed in the event that medical records are not completed promptly.
All medical records must have a handwritten or dictated discharge summary (under 48 hours, dictated summary is not required). A final progress note may be substituted for a discharge summary in the case of patients with problems of a minor nature who require less than a 48-hour period of hospitalization. A dictated discharge summary is required on the pediatric service for any patient with a hospital stay greater than 48 hours.
The discharge summary concisely summarizes the reason for hospitalization, significant findings, procedures performed, treatment rendered, condition of the patient upon discharge, and any specific instructions given to the patient and family. For the majority of patients, the discharge summary should be no more than 1-2 pages in length. Be sure to include the full name and address of the referring physician so a copy of the discharge summary can be sent to that individual.
All operative reports must be dictated immediately after surgery. Operative reports not dictated by 7:00 a.m. the morning following surgery are considered delinquent and reported daily to the Operating Room scheduling office and the Chief of Staff.
Health Information and Record Management
A Shands Hospital Committee coordinates Health Information and Record Management activities and physician, patient, and administrative needs. Do not hesitate to contact the department’s representative if you have any questions or suggestions.
Tips For would-be Dictators
- Do not hold the microphone so close to your mouth that your voice is muffled.
- Do not speak too loudly, too softly, or too hurriedly.
- Do not speak too soon after pushing the pause button.
- Do not dictate when chewing gum, eating food, or drinking.
- Do not attempt to dictate in a crowded, noisy area.
- Do not attempt to carry on other conversations when dictating.
- Do not be resistant to constructive suggestions from secretaries or transcriptionists.
- Do not dictate over another letter.
- Do not use unconventional abbreviations (e.g., FOB, NKA).
- Dictate discharge summaries at the time the patient is released from the hospital.
- When an operative report or discharge summary should be mailed to a referring physician, provide that individual’s full name and address.
- Enunciate words clearly.
- Spell difficult words, such as the names of drugs, unusual medical disorders, or complicated surgical procedures.
- When appropriate, provide precise drug dosages and dosage intervals.
- Indicate in your dictation when punctuation is necessary.
- Indicate when a new paragraph should begin.
- Use only conventional, widely accepted abbreviations.
- Be brief, concise, and coherent. Avoid unnecessary verbiage. Try to limit letters to one page and discharge summary to a maximum of two pages.
- When an operative report or discharge summary must be transcribed immediately, be certain to press the priority button when you dictate (6, then #). After dictating, please call Medical Records so that the transcriptionist is aware you are waiting for the text (5-3128). The only time when transcriptionists are not routinely available is 1:00-6:30 a.m. on Monday. On weekends, a transcriptionist is either immediately present or on call for rush dictations.
Discharge Summary Format
- Dictator’s name and service
- Attending physician’s name and position
- Referring physician’s name and address
- Patient’s name and medical record number
- Date of admission
- Date of discharge
- Chief complaint
- History of present illness
- Past medical history
- Family history
- Social history
- Review of systems if appropriate
- Physical examination
- Initial laboratory assessment
- Hospital course–include subsequent laboratory studies and diagnostic and therapeutic procedures by systems
- Final diagnoses
- Summary of procedures
- Condition on discharge
- Disposition and instructions to patient and family members
Dictation Instructions From A Touch Tone Telephone
- Dial 265-0385 from outside the hospital or 5-0385 from inside the hospital (55-0385 from Health Science Center). Listen for ID prompt.
- Enter your physician ID number followed by the pound (#) key. Listen for the password prompt.
- Enter your password followed by the pound (#) key.
- The system will take you immediately into DICTATION SERVICE.
- When prompted for a work type, press 1 # for a discharge summary, 2 # for an operative report, etc. (See work types below)
- When prompted for the subject number, enter the patient’s medical record number, followed by the pound (#) key.
- Press 2 to begin recording. There should be no tones at this time, just complete silence. If you wish to pause your dictation, press 2 to pause. To begin recording again, press the 2 again. Again, be sure to listen for any tones. A short beep every 2-3 seconds indicates you are still in pause mode and you need to press 2 to record.
- When dictation is completed, press 8 to begin a new report or the DISCONNECT key to exit from the system. If you press 8 to begin a new report, you will be prompted for a new work type and subject number.
- ** Note:To mark a dictation as a STAT, press the 6 on the Connexions dictate station any time after beginning to dictate and before doing step 8.Work Types:
- Discharge Summary
- Operative Report
- Clinic Note
- PT Note
- OT Note
- History & Physical
These instructions are also available on pocket cards for quick reference
- REWIND – Press upward on the yoke bar on the handset for a short review of your dictation. (Each beep heard indicates 2-3 seconds of rewind.) Release for automatic playback.
- TOTAL REVIEW – Press the Total Review key to move immediately to the beginning of your dictation. Playback is automatic.
- MOVE TO END – To move immediately to the last word of your dictation, press MOVE TO END key.
- HOLD – To put your dictation on hold for a maximum of five minutes, press HOLD key.