Health Information Services
Physician Handbook
2012
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Record Completion
Requirements
History & Physical Examination
Must be completed within the first twenty-four (24) hours of
admission.
Must be co-signed by the attending physician.
Operative Report
Must be dictated immediately following surgery.

Medical Staff bylaws state the responsibility for dictation rests with the attending, even if a
resident/intern has agreed to do the dictation.

Each night medical records will review all invasive procedures completed by 5 pm to identify those
without dictations. If there is no dictation, all invasive procedure areas, will be notified and the
delinquent attending(s) identified. Medical records will also send emails to the attending physician.

If delinquent attendings have cases scheduled, they will be paged by the invasive procedure area after
the 6 am notification, so that they may complete the dictation prior to the start of the working day.

Until the dictation is done, booked cases will not be allowed to start. If un-dictated for three days (3)
suspension of privileges will commence.

The invasive areas will accept the word of the attending that the dictation has been completed and their
case will be allowed to proceed.

For cases completed after 8 pm, a similar search of the dictation system will occur at noon the following
day with similar notifications.
Discharge Summary
Must be dictated/created electronically within 14 days of
discharge.

Short form required on all cases. Comprehensive discharge summary required on admission with a length of stay
greater than forty-eight (48) hours, or expirations with a length of stay greater than (6) hours.

Exceptions include: normal newborns who stay greater than 48 hours because mother stays; spontaneous vaginal
deliveries with length of stay of 3 days or less.

Short form requirements are: final diagnoses, procedures performed, hospital course, treatment given, patient
condition on discharge, and discharge instructions regarding diet, activity, medications and follow-up.
Must be signed or cosigned by an attending physician.

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Transcription of Dictated Medical Reports
Reports transcribed by Health Information Services:
Inpatient & Outpatient
Pre-Op H&Ps
Operative Reports
Cardiology Reports
(i.e. cardiac catheterizations, pre-cath evaluations, stress echocardiograms.)
Other Invasive Procedures
(i.e. endoscopies, bone marrow aspirations.)
Inpatient
History & Physical
Consultations
Discharge Summaries.
All other transcription is handled by the various clinics and departments.
Turn-Around Time:
The average turn-around time for a dictated medical report is as follows:
H&Ps – 0 to 8 Hours
Consults - 0 to 8 Hours
Operative Report - 0 to 24 Hours
Discharge Summaries - 0 to 24 Hours
Stat dictations
The following types of reports have been defined as Stat and will be transcribed by the next available
transcriptionist:

Direct transfers from UCSD to another hospital or other patient care facility, i.e. nursing home, rehab
facility.

Discharges when patient's follow-up care will be provided in another city or state.

Conservatorship summary.
All stat dictations must be identified by pressing *1 during your dictation.
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Webmedx
UCSD Medical Center Dictation Instructions
Dial 124 from a Medical Center phone or (619) 543-7131
At prompt enter your PID (physician identification number) and the # key
Enter 1 to dictate
At voice prompt, enter Work Type and the # key
At voice prompt, enter 7-digit MR number
At voice prompt, enter 1 for your location and the # key
After the Tone, Press 2 to Record Dictation
Press 5 to end dictation and be issued a job id #.
(State your name, Spell patient name, medical record number, relevant dates,
attending physician, and all providers to be cc’d on report )



Press 3 for short rewind & listen.
Press 8 to end dictation and start New Report
Press 0 at any time to be given the Job ID number for future reference.
For Assistance please call UCSD Support 543-2720 or 543-2721
(After-hours) Webmedx at 1-877-932-6339.
Dictation Key Pad Commands
1
2
3
Pause/
Stop
Record
Short
RW/Play
4
5
6
Short
FF/Play
Disconnect
7
8
9
RW/Beg
of Job
End old/
Begin
New Job
FF/End
of Job
*
0
#
*1 STAT
Job ID#
Work Types
1 - Discharge Summary
2 – Operative Report
3 – History and Physical
5 - Consultation
9 – Addendum / Edit
16 – Pain Clinic
- For STAT dictations press *1
anytime during the dictation
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Completing Your Incomplete Medical Records (non Epic)
ESA (Electronic Signature Authentication) is integrated with the hospital Patient Care Information System
(PCIS) and may be accessed 24-hours a day on computer terminals throughout the hospital.
You can also access PCIS and ESA via the UCSD Clinical Web Portal
(http:// cwp.ucsd.edu).
ESA Instructions can be found on the following page.
All transcribed reports are to be signed electronically.
ELECTRONIC SIGNATURE AUTHENTICATION (ESA)
Start ESA
1. Logon to PCIS, lower left hand corner, click on the ESA icon.
Search for Reports to Sign
1. The Dictating button is the default setting for all reports that you dictated.
2. Select OK.
Attending MD’s: You have an additional tab for co-signing all your resident and fellow reports.
Select “Attending” status to see all reports that you need to edit and/or co-sign.
To view your
incomplete charts
click on
“Deficiency Details”
This shows all your
incomplete records.
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3.
Highlight document. Double click to review.
(Glasses = Resident has reviewed, ready for attending co-signature)
Sign Report (step 1 of 2)
1. Click on the Review icon to “mark” the document for final signature. (This places a check mark next to the
document on the document list screen.).
Finalize Report (step
2 of 2)
1. Click on the Finalize icon to sign all marked reports.
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2. Enter your PCIS password and click OK.
Edit Report (if desired)
1. If editing is required, click on Edit icon.




If editing is desired, click on Edit icon.
Report opens in Microsoft Word.
Edit report.
DO NOT type below the signature line or
modify blue text.
5. To save edits: Press CTRL + S or click on the Save icon.
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End ESA
1. Click on the Cancel icon.
2. Select OK to end your ESA session.
3. Then Click on the Exit icon to return to PCIS.
If you have technical problems getting ESA to launch call 543-HELP (Outside UCSD call
619.543.7474)
If you have questions about signing/using the ESA program call: 543-2720
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Suspension of Clinical Privileges & Medical Department Fines for Delinquent
Medical Records
Notification Process:
Day countdown is from date of service for operative dictation and date of discharge for all other records.
Operative Report Dictation:

Day 0/1
Attending emailed
o All subsequent days’ procedural areas will page attending by 6am.

Day 4
Attending suspended
o All access to UCSD clinical systems will be locked out by Medical Staff Administration (PCIS,
CPOE, EPIC) until dictation has been completed.
Discharge Summary Dictation/Report Signature (op reports & dc summaries):



Day 7
Day 10
Day 12

Day 15
Provider is put on clinical suspension of privileges. Following email and page notifications,
a hard copy of the letter of suspension will be sent to the Dept Chair.
o UCSD clinical systems will be locked out by Record Completion – 7 days a week.
Provider emailed of delinquent records
Provider emailed and paged of delinquent records, Dept Chair notified.
Provider emailed and paged of delinquent records, Dept Chair notified.
The Record Completion area will initiate suspension lockout at 1pm. Lockouts can only be resolved from
7:30 – 4:00 daily.
If a provider is experiencing technical difficulties, they can notify the Record Completion office for a time extension.
There are no exceptions/extensions for operative report dictation.
As per Medical Staff By-Laws, Rules and Regulations. While on suspension, the physician may not care for
patients in an inpatient or outpatient setting. Central Scheduling will not schedule any emergent, elective, or
urgent procedures by a physician on suspension.
The reporting of physicians to the Medical Board of California for 14 consecutive days on suspension or 30 total
days on suspension in a 12-month period may occur.
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How to get an extension for record completion.
You may be granted an extension for record completion only under the following conditions:
1) You have notified the Record Completion office in writing of the dates you will be gone.
2) You have no delinquent dictations or signatures when you begin your leave.
If these conditions are met, you will be put in a "extend" status. That means no notices will be sent to you regarding
incomplete records while you are away. Physicians on rotation at other area hospitals within San Diego County are not
eligible for extensions under this policy.
Extensions may be granted for a Medical/Personal Emergency Leave as warranted. All Leaves of Absence must be verified
by the office of Chairman of your clinical department.
Email address for written notification:
[email protected]
Medical Reports
Release of information
To comply with state and federal requirements, a medical report or photocopy of the medical record
requires a written authorization signed by the patient prior to release.
Medical information should not be given via telephone to anyone other than another health care
professional when needed for continuing patient care purposes in an emergency situation.
The release of medical information via FAX is restricted to the following: Pertinent medical information
(i.e. discharge summary, operative report, radiology reports, etc.) will be released via FAX to a health
care provider in Emergency situations only, with appropriate patient authorization.
Authorizations for Release of Medical Information are available at the Nursing Stations or from Health
Information Services.
If you have any questions, problems or concerns regarding release of confidential medical information
please call the Release of Information Area (ext 36704) before any information is released.
Hillcrest Medical Center
Health Information Services is located in the basement of the South Wing.
Use the elevators servicing the Main Lobby to the Ground Level.
(The Main Lobby is the three-story atrium with palm trees.)
Exit elevators and proceed to the last door on the left side of the corridor.
Entrance (Room # L-043) for Record Completion purposes.
Hours
Hillcrest File Room:
Chart Review & Patient Care Access:
OPEN 22 hours a day, 7 days a week. Closed daily from 2-5 am.
543.6700
Completion Area:
Record Completion & Dictation:
7:30 am – 4:00 pm
543.2720
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Hillcrest File Room
Location:
The file room is located in the basement of the Outpatient Center (the building where helicopters land). Use the elevators in the Outpatient Center, go to the
basement, when exiting the elevator, turn to the right, past the hyperbaric chamber, across the hall from Neurophysiology EEG.
The following information is pertinent to records requested from the Health Information Services File Room:
A STAT request for a record should take place when the medical record is needed for direct patient care. The request document must speak to the fact that
the medical record is needed for patient care, the location the record will be taken, the name of the requestor, and the requestor’s telephone or beeper number.
Medical records needed for review should be requested twenty-four (24) hours before the actual date of review. When a record is pulled for review it will be
held for a period of forty-eight (48) hours.
Records needed for a research/study project must be requested in writing and must include a copy of the IRB approval. The following information is needed
for the request.
1.
The name of the attending physician who is authorizing the study.
2.
3.
The name of the person(s) who will be responsible for abstracting the information from the medical record.
The time period for when the records need to be provided.
4.
The number of records involved in the project.
5.
6.
Whether or not assistance will be needed in identifying the research/study population.
How the abstracted information will be utilized.
7.
The telephone or beeper number of the requester.
8.
If the collected information is going to be used in a publication and/or presentation, then the approval of the Human Subjects Department must be
obtained and their approval letter must accompany the research/study request.
* Access *
You are REQUIRED to wear a UCSD name badge whenever you enter Health Information
Services. You will not be allowed access to the charts without an ID badge.
Thornton Medical Center
No patient charts are maintained on site. All records are housed in the Hillcrest facility.
Should you require access to a patient record contact the medical records representative at Hillcrest to
request a chart delivery:
Calling from within Thornton:
Calling outside Thornton:
36700
543-6700
Charts requested will be sent via courier to Perlman Medical Records (located adjacent to the hospital).
A representative from there will notify the requestor that a chart has been delivered and is ready for pick
up.
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HIS MD Handbook 2012