section 2 - chart deficiency and tracking system
CUSTOM SOFTWARE SYSTEMS, INC MEDICAL RECORDS
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CUSTOM SOFTWARE SYSTEMS, INC MEDICAL RECORDS
CDTS - CHART DEFICIENCY
CONTROL FILE MAINTENANCE
PROGRAM PURPOSE: TO MONITOR DEFICIENCIES OF MEDICAL
RECORDS CHARTS.
Highlight option 2. Chart Deficiency/Tracking System and enter, as shown above.
The screen on the following page will then display.
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CUSTOM SOFTWARE SYSTEMS, INC MEDICAL RECORDS
Choose option 1. Chart Deficiency System and enter, as shown below.
Once entered the screen below will display.
Choose option 1. Control File Maintenance and enter, as shown below.
NOTE: Before using the Chart Deficiency System, the Chart
Deficiency Control Record must be set up.
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CUSTOM SOFTWARE SYSTEMS, INC MEDICAL RECORDS
Once the Control File Maintenance is accessed, the screen shown below will be displayed. This screen will be blank when first accessed. This is because the codes are user defined and must be set up. The screen displayed below is merely an example of what the Chart Deficiency Control
Record might look like.
Under the "Code" column, enter a user-defined code to identify items requiring completion on Medical Records Charts. Enter a brief description under the column titled "Description" to match the user defined code. Then enter the number of days allowed for completion of this item under the
"Days" column. Write the screen using 'F6'.
Once the Chart Deficiency Control Record is set up, maintenance on individual patients' records may begin, as shown on the following pages.
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PATIENT RECORD UPDATE
From the Chart Deficiency System Selection Menu, option '2' should be chosen as shown below.
After selecting option 2, the following screen will be displayed.
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CUSTOM SOFTWARE SYSTEMS, INC MEDICAL RECORDS
Enter the doctor number for whom deficiencies will be recorded. If you do not know the doctor's number, enter a '?' or press the 'F7' key for doctor lookup. Remember that 'F4' will exit the program at any time.
After selecting a doctor, the prompt to select a patient type will come up.
Choose the number that corresponds with the type of patient needed to be updated.
Select option 1 to record deficiencies on Inpatients
Select option 2 to record deficiencies on Outpatients
Select option 3 to record deficiencies on Long Term Care patients
Select option 4 to list all patient types for deficiencies
Reminder: You will be locked into whatever patient type chosen.
Upon selecting a patient type, the following prompt to enter a patient name or number will come up, as shown on following page.
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Enter Last Name, (SPACE) First Name, as shown below.
After entering a patient name, a listing of all patients with this name will be displayed along with their address and dates of service. Select the stay to be updated.
Note: 'SEL' may be typed to re-select a patient name or number.
'DDD' may be typed to enter an admission start date rather than a patient name or number.
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CUSTOM SOFTWARE SYSTEMS, INC MEDICAL RECORDS
With the exception of "fc", & "s", the headings on the screen are selfexplanatory.
The "fc" column indicates the financial class that the account is assigned to. The first digit represents the payment class, and the second digit represents the patient type. A cross-reference of these codes is listed below:
Cross Reference Table for the First Digit:
0 = Self Pay 1 = Medicare
2 = Medicaid
4 = Collections
3 = Commercial Insurance
7 = Bad Debt
Cross Reference Table for the Second Digit:
0 = Outpatient
1 = Long-Term Care / Ambulatory Care
2 = Inpatient
Example:
In Figure on previous page - line #1 the financial class for JANE DOE is 00.
Using the cross reference table, the first digit (0) means the financial class is self pay, the second digit (0) means the account is an outpatient.
The "s" column indicates the admission service assigned to this account during the admissions process. Admissions service is a user defined code that allows for the tracking of service types beyond the traditional inpatient, outpatient, and long-term care.
Enter the line number that corresponds with the patient stay to be updated, and press return.
After doing this, the screen shown on next page will be displayed.
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A cross-reference for fields above are as follows.
Code This is the user defined deficiency code set up in the Chart
Deficiency Control Record.
Description This is the description that corresponds with the user defined deficiency code.
This is also found in the Chart Deficiency Control Record.
Due-Date This is the deadline for completion of this item.
This date is calculated by adding the number of days for this item in the Chart Deficiency Control Record to the discharge date.
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Def-Code The deficiency code is chosen from the valid deficiency codes displayed at the bottom center of this screen.
They are as follows:
'C' = Complete.
'D' = Dictation is required and missing.
'N' = Not Applicable for this patient .
'S' = Signature is required and missing.
'T' = Transcription has not been completed.
Comp-Date This is the date each item is completed. If 'C' is entered as the deficiency code, you will be prompted to enter the completion date.
Location of Chart: By typing 'L' or 'LOC' at the command line, you may
Enter the location of the chart.
If something is entered here, it will update line 5 of the
Chart Tracking Maintenance Screen.
The deficiency code must be completed based on the status of the medical record chart. All other elements of this screen will be complete when the screen displays with the exception of the completion date, and it prompts off of the Def-Code 'C'.
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After recording chart deficiencies on the selected patient, the following prompt for any further desired action will come up. Enter the selection needed as shown below.
1. New Patient for Same Doctor Recording deficiencies for the same doctor on a new patient.
2. New Doctor for Same Patient Recording deficiencies for a new doctor on the same patient.
3. New Doctor for New Patient Recording deficiencies for a new doctor on a new patient.
Enter the number that corresponds with the desired actions.
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PRINT DEFICIENCY REPORT
After recording all deficiencies on Medical Records charts, there will be two reports available for review. The first of the two available reports is the
Chart Deficiency Report.
Highlight option 2. Chart Deficiency/Tracking System and enter, as shown below.
Once entered, the screen on the following page will display.
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Choose option 1. Chart Deficiency System and enter, as shown below.
Once entered the following screen will display.
Choose option 3. Print Deficiency Report and enter, as shown above.
Once entered, the screen on the following page will display.
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Choose option 1 to receive the report only.
Choose option 2 to receive the memo only.
Choose option 3 to receive both the report and the memo.
Press 'F4' to exit the program and return to the Chart Deficiency Menu.
Samples of the report and memo output are provided on the following pages.
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CUSTOM SOFTWARE SYSTEMS, INC MEDICAL RECORDS
Sample Report
Date: 09/30/99 GOOD SAMARITAN HOSPITAL
1
Time: 9:43 Chart Deficiency Report
Login Name: css For: 001 PET, SAL
CDR
Page:
3.5
Patient No Patient Name Adm Date Dis Date Hour FC
0002417 09/06/99 09/06/99 14 20
------------------Item----------------------- ---Due Date----Deficiency--
History & Physical
Discharge Summary
Consultations
Consultations - Emergency
09/08/99
09/20/99
09/08/99
09/07/99
TRANSCRIPTION
TRANSCRIPTION
DICTATION
DICTATION
Charts:
Excluding Transcription - 1
Transcription Only -
Physician Total: 1
Date: 09/30/99
2
GOOD SAMARITAN HOSPITAL
Time: 9:43
Login Name: css
Chart Deficiency Report
For: 007 SMITTE, DOLE MD
Page:
CDR 3.5
Pat No
0002417
Patient Name
SAS, LORAS
Adm Date Dis Date Hour FC
09/20/99 09/25/99 17 00
------------------Item---------------------- ---Due Date--- --Deficiency--
History & Physical
Discharge Summary
09/11/99
09/18/99
Consultations 09/18/99
Operative Report - Emerg 09/26/99
DICTATION
TRANSCRIPTION
TRANSCRIPTION
DICTATION
0026123 SPARTIN, GLADE 09/29/99 09/04/99 15 22
------------------Item---------------------- ---Due Date--- --Deficiency--
History & Physical
Discharge Summary
09/06/99
09/18/99
TRANSCRIPTION
SIGNATURE
Consultations 09/06/99
Operative Report - Emergency 09/03/99
DICTATION
SIGNATURE
Charts:
Excluding Transcription2
Transcription Only -
Physical Total: 2
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Sample Memo:
MEMORANDUM:
Date: 09/30/99
TO: Administration
FROM:
Business Office Manager
Chief of Staff
Nursing Administration
Nurses' Stations:
1 EAST
2 EAST
Fred Flinstone, M.D., President, Medical Staff
SUBJECT: Suspension of Admitting Privileges
Effective 09/30/99 the following physicians' admitting privileges have been suspended because of delinquent medical records. Admitting privileges will be reinstated following completion of records.
The dollar amount next to the physicians' name indicates the finances that cannot be billed as a result of the charts not being complete.
SMITT, DOLE MD
PET, SAL
2,684.11
160.00
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CUSTOM SOFTWARE SYSTEMS, INC MEDICAL RECORDS
PRINT CHART PULL LIST
After recording all deficiencies on Medical Records charts, there will be two reports available for review. The second report available for reviewing chart deficiencies is the Chart Pull List.
This is simply a list of deficient charts to be pulled and worked along with a letter (if requested) to the doctor alerting them of their deficiencies. The screen shown below will display when '4' is entered.
CHART PULL LIST
Enter Selection: __
1. - Process Report Only
2. - Process Letter Only
3. - Process Report & Letter
4. - Return to Chart Deficiency Menu
'F4' - Chart Deficiency Menu!
Press '1' to process only the Chart Pull List Report.
Press '2' to process the letter only.
Press '3' to process both the Chart Pull List Report and Letter.
Press '4' to return to the Chart Deficiency Menu
A sample Chart Pull List Report with letter is shown on the following pages.
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CUSTOM SOFTWARE SYSTEMS, INC MEDICAL RECORDS
Sample Report
Date: 09/30/99 GOOD SAMARITAN HOSPITAL
1
Time: 9:15
Login Name: css
Chart List
For: 007 SMITT, DOLE MD
CPL
Page:
3.1
Pat No Folder # DTS Patient Name Date Adm Date Dis Comments
02417 68137 DT SACK, LORA 09/20/99 09/25/99 BUS OFF
26123 74246 DTS SARTIN, LEE 09/29/99 09/04/99
Charts:
Excluding Transcription - 2
Transcription Only
Physician Total: 2
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CUSTOM SOFTWARE SYSTEMS, INC MEDICAL RECORDS
Sample Letter
GOOD SAMARITAN HOSPITAL
1234 GETWELL DRIVE
ANYTOWN, USA 12345
Date: 09/30/99
Dear Dr. Smitt
You have incomplete medical records in need of the following items.
Those in the overdue column are included in the total number of charts needing completion.
----------------------------------------------------------------------------------------------------
Item to be completed | Total # of Charts | # Charts Overdue
----------------------------------------------------------------------------------------------------
History & Physical
Discharge Summary
| 1
| 1 |
| 1
1
Consultations | 1
Consultations – Emergency | 1
|
|
1
1
----------------------------------------------------------------------------------------------------
Please complete the OVERDUE records prior to 10/04/99 or admitting privileges will be revoked.
Thank you,
F. Flinstone, M.D.
President, Medical Staff
*SIGNATURES @ $5,238.22
*DICTATION @ $2,749.11
GRAND TOTAL $7,987.33
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CUSTOM SOFTWARE SYSTEMS, INC MEDICAL RECORDS
CDTS - CHART TRACKING
PATIENT RECORD UPDATE
Choose option 2. Chart Deficiency/Tracking System and enter, as shown below.
Once entered, the screen on the following page will display.
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Choose option 2. Chart Tracking System and enter, as shown below.
Once entered the screen below will display.
An explanation of each of these options is provided on the following pages.
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Select option 1. Patient Record Update and enter, the following screen will then display.
Select the appropriate patient type, keeping in mind that you will be limited to the patient type selected. Upon selecting a patient type, the following prompt to enter a patient name or number will display. Enter the name
Last Name, (SPACE) First Name as shown below, or the patient number, if known.
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After entering a patient name or number, a listing of patients with this name or number will be displayed along with their address and dates of service.
With the exception of "fc" &"s", the headings on the screen are selfexplanatory. The explanations for these three headings can be found in on page 8 of the 'CDTS' section.
After selecting the line number for the stay to be updated, the screen shown below will be displayed.
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This screen will be blank when first accessed. Completion by the user is required for using the Chart Tracking program.
A cross-reference below details individual field information for the screen above.
Person Taking Chart Enter the name of the individual who is taking the chart.
Date Taken
Time Taken
Reason Taken
Enter the date the chart leaves the Medical
Record Dept.
Enter the time the chart leaves the Medical
Record Dept.
Enter the reason the chart is being taken.
Location of Chart
Phone or Ext#
Return Chart To
Enter the location of the chart after it leaves the
Medical Records Dept.
Enter the phone number or extension number for the location of the chart
Enter the name of the person in Medical
Records that the chart should be returned to.
Remember that you may write this screen by typing "WRT" or by pressing
'F6'. You may exit the program by typing "END" or by pressing 'F4'.
Finally, you may delete this record for chart tracking purposes by typing
"DEL" or by pressing 'F8'.
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CUSTOM SOFTWARE SYSTEMS, INC MEDICAL RECORDS
PRINT CHART TRACKING REPORT
Choose 2. Chart Tracking System and enter, as shown below.
To produce this report, press option '2' as shown below.
After pressing '2' the following screen will be displayed.
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The user must then press the option number corresponding to the order in which they want the report printed.
Choose '1' to print in the order of the person taking the chart
'2' to print by chart location
'3' to print by patient number
'F4' to exit the program.
After selecting a report order, the screen will ask if the input is correct or incorrect. Press 'Y' if the information is correct, or press 'N' to correct the input.
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Sample Report
Date: 09/30/99
Time: 8:25
Login Name: css
GOOD SAMARITAN HOSPITAL
Chart Tracking Report
Pat-No Patient Name Adm-Date Dis-Date Hour FC Phone/Ext# Return-Chart-To
Person-Taking Chart Date Time Reason-Taken Location-of-Chart
----------------------------------------------------------------------------------------------------
09997 SMITH, JON 09/25/99 09/25/99 09 10 936-2456 Mary Smith
Mary Tate 10/01/99 9:28 Patient disputing bill Business Office
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