New Physician Orientation Information - Valley Hospital

THE VALLEY HOSPITALMEDICAL RECORDS DEPARTMENT1. Medical Record Important Procedures to follow:• The Final Diagnosis on the Face Sheet must be completed at the time of the Patient’s discharge.• History and Physicals must be dictated or hand written within 24 hours of the patient’s admission. Forelective admissions the History and Physicals must be available upon admission. Patients cannot go tothe OR without an H & P.In order for dictated H & P’s to be available 48 hours prior to elective admissions, as required by theMedical Board Policy, reports must be dictated at least 72 hours in advance.*History and Physicals are valid for 30 days. If the patient arrives after the 30 day allowance, a newHistory and Physical must be dictated. Any History and Physical that is done over 7 days prior to thepatient admission, must be updated by completing the stamp shown here:NO INTERVAL CHANGESINITIALS_______________DATE __________________Please note that if indeed there are changes to the patient’s present condition, an addendum must becompleted at that time.If the patient is a Same Day Surgery patient or is in the hospital for a stay no more than 24 hours, ashort stay form may be used.• Operative reports must be dictated immediately after the procedure and a postoperative progress notemust be written immediately after surgery. Please remember: All Operative reports must be donewithin 24 hours of the surgery.• A discharge summary should be dictated at the time of discharge.• No medical record shall be removed from the hospital at any time, except when subpoenaed.2. DRG’s / CodingIn order to facilitate the coding and DRG assignment process, the following information should be reflected on thechart when it arrives in Medical Records:• History & Physical• Informative, timely progress notes• Operative Report• Final Diagnosis documented by the time of discharge on the face sheet* Please note that if the diagnosis is not present in the record at the time of the coding process, a final diagnosisquestion will be asked to the appropriate physician. These records are time sensitive and extremely important inorder for the reimbursement process to take place.* Please try complete charts with Green Folders around them as soon as possible.1

3. Incomplete Medical RecordsIncomplete medical records are stored in the Medical Record Department “Doctors Room”. The incomplete recordsare filed by medical record number. It will be helpful for the physician to call Ext. 8106 before coming in tocomplete charts. Suspension is every two weeks on Thursdays by noon.* See Medical Staff Rules for our Chart Completion Policy.Physicians can also request to be placed on a regular weekly schedule so that they may continuously come in tocomplete their medical records. Please call ext. 8106 to make arrangements. Please note that all records stay out for only 1 week, and are returned from the physician’s pull toallow other physicians the opportunity to complete their portion. Any chart over 30 days post discharge is subject to suspension.4. Dictation ProcedureDirections should be followed on the Valley Hospital Digital Voice Digital Dictation Tone Controlled InstructionCard. Please make sure that the correct dictation number assigned to you is used at all times.On Premises : Dial : Ext. 8699Off Premises : Dial : (201) 447-8699*All reports must be dictated separately. Please dial the #5 on the telephone number pad to dictate the nextreport when using the Medquist Digital Dictation System.*If a physician needs to make any dictations a STAT, please contact the department to do so.General Information:• Doctors receive one copy of all their dictation on a regular basis in their hospital mailboxes.• If a physician is not on Valley’s staff, then the dictating physician’s office has the responsibility to make andmail any additional copies.• Requests will be fulfilled within 5 working days unless otherwise noted and approved by management.5. Electronic SignatureElectronic signature is available via Meditech for all dictated reports. Training takes 5 minutes. Please keep inmind that the physician will need to create a six character pin number when using electronic signature. Anycombination of numbers or letters may be used. Please contact Karla Franqueira at ext. 8109 to makearrangements for sign-up and training.6. Physician Requests for Information• In keeping with hospital policy and patient confidentiality, no information will be given out to physicians whoare not treating the patient, without patient authorization.• Copies of patient information requested by physician offices are placed in the Doctor’s mailbox.• Requests for faxing of patient information to Doctor’s offices is done in emergent situations only and requires apatient’s authorization.• Requests for chart audits are accepted no less than one week prior to the date the review needs to take place. Allrequests must include the patient name, medical record number, and discharge dates in order to be processed.Requests are filled : Monday – Friday 10:00 A.M. – 4:00 P.MF:\home\dsarra\WORD\PhysicianOrientation.doc2