Medical Record Completion/Documentation FAQ’s

 
  1. What is required to be included in an H&P, Discharge Summary, Operative Note, and Clinic Note?
  2. Can I still dictate these notes and how do I dictate?
  3. When is a discharge summary required?
  4. Who is responsible for dictating or entering the discharge summary?
  5. When is an operative note required?
  6. When is a history and physical note required?
  7. When may verbal orders be given and how do I know that I need to sign a verbal order?
  8. When is a discharge order form or discharge progress note necessary?
  9. How do I make a correction in the medical record?
  10. Can abbreviations be used in the medical record?
  11. Can I be suspended or my paycheck delayed because I do not complete medical records?
  12. Can my clinical privileges be suspended for failure to complete records?
  13. How is the “attending physician” determined?
  14. When are records reviewed after discharge?
  15. Why are deficiencies that are not mine assigned to me?
  16. When is a medical record “complete”?
  17. When is a medical record “delinquent”?


 

What is required to be included in an H&P, Discharge Summary, Operative Note and Clinic Note?

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History and Physical Examination
Chief Complaint
Details of Present Illness
Relevant past, Social and Family Histories
Relevant Psychosocial Needs
Report of Physical Examination
A statement on the conclusions or impressions
drawn from the admission history ad physician examination
A statement on the course of action planned
Signature, Date and Time
Document participation by the attending physician
(if appropriate)
Clinic Note
Name of Patient
Medical Record Number
Dates of Visit
Practice Site
Referring Physician / Agency
Reason for Visit
History of Present Illness
Past Medical History
Past Surgical History
Allergies
Current medications
Social History
Family History
Review of Systems
Physical Examination
Problem List
Plan of Care / Disposition
Dictator Name and Title

Discharge Summary
Name of Patient
Medical Record Number
Dates of Admission and Discharge
Name and Address of Referring Physician(s)
Reason for Hospitalization
History of Present Illness
Past Medical History
(These items should be brief, do not duplicate entire
history and physical exam documented on admission.)
Medications
Social and Family History
Previous Surgery
Allergies
Review of Systems
Physical Exam
Significant Findings
Hospital Course
Condition of patient upon discharge
(include disability status)
Discharge Medications
Discharge instructions
(to patient / family)
Discharge Diagnoses Procedures / Operations
Dictator name and title
Attending name and title
List to whom copies are to be sent
Operative Note
Name of Patient
Medical Record Number
Date of Procedure
Procedure performed
Pre-Op Diagnosis
Co-morbidities
Post-Op Diagnosis
Resident Surgeon
Name of Teaching (attending) Surgeon(s)
Name of First Assistant
Type of Anesthesia
Complications
Fluid replacement
Prosthesis Placement (implants)
Indication for Procedure
(brief sentence or two)
Sponge, Needle, Instrument Count
Drains and Stent Replacement
Specimens Removed
Operative Findings
Description of Procedure
Name of Dictator/Author​
 

Can I still dictate these notes and how do I dictate?
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The note types in the grid below can be dictated and discharge summaries are encouraged to be dictated at this time to produce a professional, typographical error free document for continuity of care.


  1. From a touch tone phone, dial 706-721-0214.
  2. Enter your Medical Identification Number (5-digit dictation number).
  3. Enter the 9-digit Medical Record Number (Include leading zeros).
  4. Enter the appropriate Work Type (Choose from list below).

    Type Description
    ​1 ​Operative
    ​2
    ​Practice Site Note
    ​3 ​Practice Site Letter
    ​4 ​Discharge Summary
    ​5 ​STAT Report
    ​6 ​Emergency Services Note
    ​7 ​History and Physical
    ​8 ​Psych Practice Site Clinic Note
    ​9 ​Psych Practice Site Letter
     
  5. Enter the 4-digit visit suffix (The last 4 digits of the 13 digit account number).
  6. After hearing the double-beep, press 7 to begin. 
  7. For each dictation, BEGIN by stating:
    • Your Name
    • Type of note your dictating
    • Patient's name (include spelling)
    • Medical Record Number
    • Date of Visit / Procedure
    • Service or Name of Clinic
    • Name of Attending (if dictated by resident
  8. For each dictation, END by "hanging up" or pressing the # key then 1 (to continue to your next report). 

Other Help Functions

​1 ​Rewind to beginning / play
​4 ​Short review of dictation
​5 ​Extended pause (up to 5 minutes)
​7 ​Dictate / un-pause

 

Error correction
Rewind to point of correction, press 5 to pause and then press the # key then 7 to record over previous dictation.

Insertions
Rewind to the point of insertion, press 8 and dictate statement, then press 5 to pause, and press 4 to rewind and review what you have inserted. If needed, press 7 to go to the end of the dictation and continue dictating the remainder.


When is a discharge summary required?
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A Discharge Summary should be dictated or entered at the time of discharge and is required on all discharges from nursing units (including psych patients and patients who leave against medical advice) with a length of stay which exceeds 48 hours except:


 

  • Short Stay patients with problems of a minor nature (hospitalization is less than 48 hours and patient is discharged alive). Note: The Trauma Service requires a dictated or entered discharge summary on all discharges regardless of the length of stay.
  • Uncomplicated obstetrical deliveries, defined by the Department of OB/GYN as resulting in a normal fetal outcome (gestational age greater than or equal to 37 weeks and birth weight greater than or equal to 2500 grams); no significant maternal complications; and no surgical procedures (C-Section, hysterectomy, D&C for retained placenta). A tubal ligation following a normal delivery does not require a discharge summary.  Note:  The OB Service requires a dictated or entered summary on multiple gestations and stillbirths.
  • Normal newborns, as defined by the Section of Neonatology, Department of Pediatrics as an infant admitted to the 7W nursery or admitted to/transferred to the NICU for a period of 24 hours.


A dictated or entered death summary is required on all patients who die at GRMC, regardless of length of stay.  The only exception to this is infants admitted to the NICU for hospice care for extreme prematurity.  In these cases, a death note providing details related to birth is appropriate.

All discharge summaries must be signed by the attending physician at the time of discharge.


Who is responsible for dictating or entering the discharge summary?
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The person who discharges the patient is responsible for dictating or entering the discharge summary. In general, the person who signs the Discharge Order Form or Discharge Progress Note is the person assigned the dictation deficiency if the summary has not been dictated, entered, or otherwise specified at the time of record analysis.


When is an operative note required?
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An Operative Note is required for all procedures performed in the main Operative Suites and Ambulatory Surgery Units at GRMC and CHOG.  An operative note is also required for any procedure performed in an intensive care unit or patient room if personnel from Operative Services assist with the procedure. Operative notes should be dictated or entered, or a Procedure Note created, immediately following the procedure. A procedure note must contain the name(s) of the primary surgeon(s) and his or her assistant(s), the name of the procedure performed, findings, postoperative diagnoses, estimated blood loss and specimens removed.  All operative notes must be signed by the attending surgeon.


When is a history and physical exam required?
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The History and Physical Note must be recorded within 24 hours of admission and prior to surgery. A history and physical examination recorded during a previous hospitalization or clinic visit within 30 days for the same or related condition will suffice as long as it is updated within 24 hours of admission and prior to surgery. The attending physician must add a teaching statement and countersign the report if it is used as documentation to support professional billing. 

The H&P shall be proportionate to the complexity and medical condition of the patient and shall meet the standards of care for that area of practice.

*Note: H&P's are only good for 30 days. Updating an H&P older than 30 days will not serve as a valid H&P.*


When may verbal orders be given and how do I know that I need to sign a verbal order?
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Verbal Orders should only be used in urgent situations. When written on paper, the nursing unit staff will flag all verbal orders for signature and these should be signed at your next visit to the unit.  When done electronically, these orders will appear in your Cerner Message Center for signature. These orders should be signed immediately. 


When is a discharge order form or discharge progress note necessary?
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A Discharge Order Form or Discharge Progress Note must be completed on all discharged patients (including bedded outpatients, observation, inpatients and patients who leave against medical advice) and contain diagnoses, procedures, and other information pertinent to continuity of care including outcome of hospitalization, final disposition and provisions for follow up care.


How do I make a correction in the medical record?
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When correcting an error on paper, the care provider should draw a single, horizontal line through the original entry in such a way that the original entry remains legible. The original record should not be altered in any way by trying to erase or remove the incorrect information. The care provider should print the word "error" at the top of the entry, and initial, date, and time it.  Document the correct information.

Once documents have been sent to HIMS for scanning into the electronic patient record, or for errors within the electronic record, any corrections to these documents must be made through HIMS.  Contact the Workroom staff at 1-3050 for assistance.


Can abbreviations be used in the medical record?
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Only those symbols and abbreviations approved by the medical staff may be used in the medical record. Symbols and abbreviations may not be used when recording final diagnoses.


Can I suspended or my paycheck be delayed because I do not complete medical records?
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Yes. If a resident/fellow has one delinquent record with a missing operative note or more than one delinquent record with a missing discharge summary or five or more delinquent records with other signature deficiencies, HIMS may interrupt the direct deposit process.  Manual paychecks must be picked up from the Graduate Medical Education Office.  If the delinquencies are not cleared by Pay Day, the Resident will be required to pick up his or her paycheck from the appropriate Clinical Service Chief, who will provide counseling regarding the importance of timely completion of medical records. 

Should the resident have subsequent need for counseling, he or she will be subject to suspension without pay by the Sr. Associate Dean for Graduate Medical Education.   To avoid suspension, the House Officer must provide verification from HIMS to the Graduate Medical Education Office that they are no longer delinquent.

For more information, refer to the "Medical Staff Rules and Regulations, B33".


Can my clinical privileges be suspended for failure to complete records?
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Yes. If an attending physician has one delinquent record with a missing operative note or more than one delinquent record with a missing discharge summary or more than five delinquent records with other signature deficiencies, the Department Chairman may recommend to the Chief-of-Staff that clinical privileges be suspended.


How is the "attending physician" determined?
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For the purposes of record completion, the attending physician is defined as the faculty member responsible for patient/service at the time of admission, surgery and discharge. There may be more than one attending physician during the course of hospitalization but the attending physician at the time of discharge is responsible for completion of the medical record.  It should be clear from the admission orders and subsequent transfer orders who the attending physician is at any point throughout the hospitalization.


When are records reviewed after discharge?
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Records of patients discharged or departed from nursing units (inpatients, bedded outpatients, and observation patients) are reviewed for physician deficiencies 3-5 days following receipt of the discharge packet from the nursing unit.  (During the 3-5 days after discharge, we are busy prepping, scanning and filing the new material.)  While the discharge packets should be available to HIMS on the evening following the day of discharge, there are occasions when this is not the case.  You can help with this process by not removing discharge packets from the nursing unit.


Why are deficiencies that are not mine assigned to me?
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Record analysis is frequently difficult because of signature legibility issues, cross-cover and same or similar names.  While we do attempt to determine the correct person to assign the deficiency to, errors are possible.  For the electronic record, deficiencies can be assigned in error by other physicians.  If a deficiency is assigned to you in error, please let us know by contacting the Workroom at 1-3050.


When is a medical record "complete"?
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A medical record shall be considered complete when the:

  • History & Physical Exam is present and signed by the examiner.
  • Discharge Summary (if applicable) is signed by the attending physician and is filed in the record.
  • All operative reports are signed by the attending surgeon(s) and filed in the record.
  • All consultation requests/replies in the record are signed by the requestor and consultant.



When is a medical record "delinquent"?
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Thirty days following discharge if any of the following are missing or not signed:

  • History & Physical Exam
  • Discharge Summary (if applicable)
  • All operative reports
  • All consultation requests/replies