Resident Orientation
Health Information Management Department
(HIM)
Authentication Form
Authentication form needed in the event you sign any documents on paper.
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HIM Location & Hours
Location:
• 4th Floor, South Building
• Chart Analysis Area Phone: 336-716-3219
• After Hours Phone: .336-716-4787
Hours of Operation:
• Monday-Friday – 24/7 –
• Weekends – Call on-call supervisor
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Where are Medical Records
Maintained?
• Most patient documentation can be found in WakeOne (Electronic Health RecordEHR) in various tabs located in individual charts.
o Encounters, notes, Meds, Labs, Micro, Imaging, Procedures, Cardiology, Other Orders,
Episodes, Letters, Referrals, Media, Misc Reports, Pat Sum Extracts
o Scanned documents can be found on the media tab.
o Historical documents are located under Historical Documents button above the
tabs. This is through On-Base.
• Paper records filed in Medical Records – On Campus Storage – Prior to 10/2006
• Off Campus locations – various clinic locations still have some paper medical
records on site.
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Health Information Management
Standards
• Removing Medical Records from Inpatient Nursing
Units or Hospital Premises.
• Release of Medical Information
o Must Follow HIPAA Rules.
o Forward to Release of Information Office in the Health Information
Management Department.
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HIM Intranet Site
http://intranet.wakehealth.edu/Departments/Health-Information-Management/
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Dictation
**WFBH preference is for providers to type notes but
dictation is available.
**HIM will provide dictation cards to Residents
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Dial In Dictation Instructions
Dictation Card
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Partial Dictation Instructions
Partial Dictation Instructions
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Electronic Authentication
Performed in WakeOne through the In-Basket Folders
• Must electronically authenticate all documents you dictate.
• Electronically sign documents DAILY.
• Dictated items fall into the Transcription folder in the in-basket, but can
also be found in the Hospital Chart Completion folders by patient and note
type, as well as My Open Charts for outpatient clinic notes.
• Unauthenticated documents flow to WakeOne as soon as transcribed –
before authentication. When authenticated, document will update with any
changes.
• Attending Physicians required to electronically countersign much of what
House Officers dictate - - History/Physicals, Operative Reports, Discharge
Summaries.
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Paper Documentation
• Must be legible
• Date and Time All Entries
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Documentation Standards
Copy-Paste or Cloning
•
Providers are required to document in compliance with all federal, state, local laws and Medical Staff Rules
and Regulations.
•
The writer/author of each document is responsible for all of the content of that document, and must ensure
that any material copied into that record accurately reflects the care provided during that episode of care.
•
All copied information from other electronic sources shall be credited to the author.
•
It is appropriate to copy and include information needed to support clinical decision making and the care
rendered during a specific episode of care. However, summarization of any records, test results, etc. is
strongly encouraged.
•
The copying of information from one patient record to a different patient’s records is prohibited
except in the circumstance when documentation was entered in error.
•
Cloning of documentation is not allowed.
•
When it is necessary for clinical care, to copy information from the note of one provider to another provider,
the Information copied should be referenced to include date, time and author of the original entry.
•
Information copied from a previous note by the same author should include only that information that is
unchanged.
•
Copy/paste or copy/carry forward of student notes is prohibited.
•
Copying Teaching Physician attestations from previous notes is prohibited.
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Documentation Standards (con’t)
Prohibited Abbreviations
• Cannot use in any handwritten documentation, computer text entry,
or pre-printed forms.
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Documentation Timelines
Responsibilities for documenting and/or completing medical records
vary by clinical service. If not told, please Ask!!!
• History and Physical
o Must be completed within 24 hours of admission or prior to surgery.
 If a H&P has been completed within 30 days of admission, this H&P may be used,
but must be updated at the time of admission or prior to surgery.
• Operative Notes
o Dictated report or manually created report required within 24 hours.
o Must document brief op note immediately after surgery before transition to
next level of service (unless full note is done immediately).
• In-Patient Progress Notes
o Must be completed daily.
o Attending must co-sign.
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Documentation Timelines (con’t)
• Discharge Summary
o Complete on Day of Discharge.
o Dictate or manually type in WakeOne; preferable type your note.
o Be careful to select the correct admission.
• Clinic Notes
o Must be documented by the provider as soon as possible the day of clinic
visit, but no later than 24-48 hours.
o Method of documentation determined by clinic (options include partial
dictation, full dictation, or manually creating).
• Admission Orders
o Signature or countersignature required (within 48 hours) of the inpatient
admission order by the certifying physician (the order).
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Documentation Timelines (con’t)
• Verbal and Inpatient Orders
Refer to Provider Physician orders policy:

http://ishare.wakehealth.edu/GoverningPolicy/Policies/Provider Physician Orders.pdf
o The hospital minimizes the use of verbal and telephone orders. Telephone and
verbal orders should be accepted only when a prescriber does not have ready
access to the electronic health record, e.g., scrubbed in sterile procedure, engaged
in a code situation.
o Telephone/verbal orders should not be accepted for admission orders, other routine
orders or for antineoplastic (chemotherapy) agents.
o Signatures/Countersignatures require the signature of the provider, date and time of
the signature. The ordering provider should sign all verbal and telephone orders
within one week (seven days) of the time the order was given.
o Orders written/entered by a medical student, physician assistant student, scribe or
Acting Intern will be pended until co-signed electronically by the responsible
physician before the order becomes active and the nurse can see the order in the
order profile and carry out the order. It is the responsibility of the prescriber to
obtain the appropriate signatures. Electronic order entry, including activation of
pended orders in WakeOne is not allowed beyond 2 hours following patient
discharge.
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Chart Analysis
• Key documents for analysis post discharge/visit
o History and Physical
o Operative Note
o Telephone Verbal Orders
o Discharge documentation and/or Discharge Summary
If above documentation is missing and it is determined you are the responsible
physician, a deficiency will be assigned to you. This can be found in your in-basket.
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Deficiency Reporting
All provider documentation is considered delinquent at 7 days.
Documentation must be complete within specified timeframes of
document type such as H&P complete within 24 hours, clinic notes
within 24-49 hours, etc.
• 7 day reporting – Time frame = Sunday – Saturday
o Routine Reports re sent to Providers/Residency Coordinators – Tuesday,
Wednesday, Friday
• Faculty/house staff will have until Monday 2 pm to complete records
• Final Report Sent – Mondays
o Chairs will determine which providers will be granted Amnesty or placed on
Administrative Duty by 3 pm Monday.
o If provider completes charts on Monday, providers should notify Chair/BA and
HIM when charts are complete.
NOTE: Residents should note if they complete work at the 7 day point, attendings will be held
accountable for the deficiency.
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Deficiency Reporting (con’t)
• Amnesty or Administrative Duty – Tuesdays
o Department Chair will reassign faculty/house staff to
administrative duties until HIM certifies all records are up to date
o If granted Amnesty Chairs should indicate
 Reason for Amnesty
 Length of time for Amnesty (preferably no longer than 7 days)
 Providers will be given a timeline for completion
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Thank you
Please call us if you need our assistance
Welcome to Wake Forest Baptist Medical Center
Wake Forest Baptist Medical Center