CREIGHTON SAINT JOSEPH MEDICAL STAFF
BYLAWS, POLICIES, RULES AND REGULATIONS
MEDICAL RECORDS POLICY
I.
II.
Responsibility for Medical Records:
A.
The attending practitioner is responsible for a complete and legible medical record on
each patient which documents justification for the hospital stay. Illegible signatures must
be supplemented by printed name.
B.
Entries by House Staff and Mid-Levels (as an agent for in and in the name of their
supervising/collaborative physician) shall include the history and physical examination,
operative reports, orders, progress notes, consultations, and discharge summary.
C.
Medical student entries on the medical record shall be limited to progress notes.
D.
Care provided by all caregivers shall be documented as appropriate in the medical
record. The Forms Committee will approve all forms used to document this information.
Guidelines for documentation will be the responsibility of the department providing
service.
E.
All dictated reports must have:
1.
Patient Name
2.
Account Number
3.
Date of Admission, or date of consultation, or date of operation
4.
List of physicians for sending copies
5.
Type of report.
F.
Failure to comply with these regulations may result in suspension of admission privileges
after the practitioner has been advised of his delinquency, as outlined in the Policy on
Appointment, Reappointment and Clinical Privileges.
G.
Inappropriate remarks shall not be dictated or written in the medical record.
Contents of the Medical Record shall include:
A.
Identification data.
B.
Admitting diagnosis.
C.
Principal diagnosis
(1)
Secondary diagnosis
D.
Principal procedure
(1)
Secondary procedure
E.
Discharge summary signed and dated by the attending physician
F.
Discharge order form signed and dated by a physician.
G.
History and physical signed and dated by the attending physician.
H.
Operative report(s) (if applicable) signed and dated by the attending
surgeon.
I.
Consultation report(s) (if applicable) signed and dated by the consulting
physician.
J.
Orders signed, dated, and timed.
K.
Progress notes signed, dated and timed.
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III.
L.
Diagnostic and therapeutic orders signed, dated, and timed.
M.
Diet and/or nutritional support orders signed dated and timed.
N.
Clinical observations including results of therapy.
O.
Reports of procedures, tests and their results.
P.
Autopsy reports to include provisional anatomical diagnoses and completed record
(when applicable).
Q.
American Joint Commission on Cancer staging on newly diagnosed cancer must
recorded on the medical record by the managing physician on initial diagnosis. These
may be clinical or pathologic, whichever is appropriate. Both are not required.
Retreatment staging may be reordered at the discretion of the physician.
R.
Patient Coding Sheet.
S.
The current obstetrical record will include a complete prenatal record. The prenatal
record shall be a legible copy of the attending practitioner’s office record transferred to
the Hospital before admission.
History and Physical:
A. All patients put to bed, whether inpatient admission or observation shall be required to have
a complete history & physical documented on the medical record.
B.
Time Requirements: A medical history and physical must be completed within 24 hours
of admission.
C.
If the history and physical is completed 30 days prior to the admission, update to the H&P
must be documented at the time of admission or prior to surgery/invasive procedure.
The update can be “no changes.” The update can be documented in the progress notes
or on an H&P form.
D.
The H&P completed by a practitioner who is not a CUMC Medical Staff member will be
accepted as long as it meets the completion and content criteria as outlined in this policy
III (c) and (d). The review and updating of that H&P as outlined in section III (c) will
constitute the signing of that H&P.
E.
Content of History and Physical:
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
F.
Records Permitted in Lieu of Admission History and Physical:
(1)
G.
A comprehensive consultation, which includes a history and physical, may be
used in lieu of a history and physical examination.
Requirement for History and Physical before Surgery/Invasive Procedure:
(1)
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Chief complaint, admitting diagnosis
Present illness
Past history (including allergies, current medications and
conditions)
Relevant family history and social history
Review of systems
Pertinent Physical Exam
Treatment plan (Plan of Care)
Impression
When the history and physical examination are not recorded before surgery or
invasive procedure, the procedure shall be cancelled.
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H.
(2)
If the attending physician or surgeon states in writing that such delay would be
detrimental to the patient, the procedure can be performed, however, the History
and Physical Examination shall be dictated within 24 hours.
(3)
For “pre-operative patient” one MUST include a statement regarding discussion of
risks, benefits, options and potential complications of the procedure, as well as
blood transfusion, if applicable.
Outpatient/Ambulatory Surgery Documentation: It is the surgeon's ultimate
responsibility to assure that an adequate preoperative assessment, appropriate to the
planned procedure is completed and documented.
Minimum requirements for Outpatient Surgical Pre-Operative Assessments are as
follows:
A history is required regardless of the type of anesthesia planned and/or given,
as well as when no anesthesia is given. The history must at a minimum include
documentation of:
1.
2.
3.
4.
indication/symptoms for surgical procedure;
a list of current medications and dosages;
any known allergies, including medication reactions;
existing co-morbid conditions, if any.
The extent of documentation required in the physical examination is to be
reflective of the type of anesthesia planned and/or given according to the
following hierarchy.
No Anesthesia or topical, local or regional block:
(a)
(b)
(c)
assessment of mental status and,
an examination specific to the procedure proposed to be performed and
comorbid conditions.
Vital signs (TPR & BP)
IV Sedation
(c)
a , b and c above and
(d)
examination of heart and lung by auscultation.
(e)
ASA Physical Status Classification.
General, spinal or epidural anesthesia
(e)
(f)
IV.
a, b, and d above and
assessment and written statement about the patient's general condition.
Progress Notes:
A.
Pertinent progress notes shall be recorded, timed and dated at the time of observation.
B.
It is the responsibility of a staff physician or Chief Resident/Fellow to daily countersign
the house staff or medical students progress notes, or to indicate his/her involvement in
care of a patient with a note of his/her own. The day of discharge may be excluded.
1. Mid-levels as an agent in and in the name of their supervising/collaborative
physicians are exempt from this requirement.
C.
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Whenever possible, each of the patient's clinical problems should be clearly identified in
the progress notes and correlated with specific orders as well as results of tests.
Progress notes shall reflect the response of the patient to treatment.
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V.
Procedures at bedside
A. When a procedure is performed at bedside, the physician must assure that a procedure
note is entered into the medical record. Minimally, this note must state rationale for
procedure, and status of the patient post procedure. This note must be dated, timed and
signed.
VI.
Operative Reports must be dictated on the day of procedure.
A.
VII.
VIII.
The individual who is responsible for the patient shall record a preoperative diagnosis
prior to surgery.
B.
All operative reports must contain:
1.
Date of operation or procedure
2.
Preoperative diagnosis
3.
Postoperative diagnosis
4.
Operative title/procedures performed
5.
Surgeon name
6.
Assistant surgeon
7.
Anesthesia type
8.
Indications and findings
9.
Procedures detail (technical description)
10.
Laceration/wound – (length and width)
11.
Specimens removed
12.
Sutures/drains – type of closure (e.g. layered, intermediate closure)_
13.
Estimated blood loss (document replacement if given)
14.
Disposition/condition
15.
Complications, if any
C.
The postoperative summary or note shall be written in the medical record by the surgeon
immediately following surgery.
Consultations:
A.
All requests for consultations shall be documented in the medical record.
B.
Consults should include reason for consultation and date of consult. Consult reports shall
be signed and dated by the consulting physician. Consults handwritten in the progress
notes must be authenticated by the attending physician if he/she did not provide the
consult.
Orders for Treatment of Patients:
A.
All orders for treatment of patients shall be in writing.
(1)
The practitioner's orders must be written clearly, legibly and completely.
(2)
Orders which are illegible or improperly written shall NOT be carried out until
rewritten or understood by the nurses.
(3)
All orders shall be dated and timed.
(4)
Staff practitioners may permit appropriately licensed house staff members to write
orders and conduct care for their patients under supervision. Granting this
privilege
to house staff members does not prohibit orders to be written by the
attending staff practitioner or without permission of the house staff member.
(a)
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Nonparticipation in this practice by a staff practitioner shall not in
itself be the basis for privilege or membership sanctions to be used against
the practitioner.
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(5)
Blanket orders for medications and treatments are unacceptable. Medication and
treatment orders must be specific. The terms Resume, "Renew", "Repeat" and
"Continue Orders" are not acceptable. All medication orders must include the
medication name, dosage, frequency, and route of administration. The use of “on
call” or ‘prn” with medications shall be qualified in terms of condition or situation
for which the medication is prescribed, and time or time interval or maximum dose
per time period (e.g. PRN pain, PRN fever). Orders without his component are
not considered valid and will not be executed.
(6)
All previous orders are cancelled when a patient goes to the Operating Room.
New orders are required post operatively.
(7)
Medication orders must be written or reconciled at the time of admission and
transfer or discharge.
B.
IX.
Telephone Orders: Only licensed, registered or credentialed personnel may take
telephone orders, which relate specifically to their scope of practice.
(1)
Medical Assistants may call with verbal orders from their physicians for tests.
(2)
Any professional who receives a telephone order must document the order in the
patients medical record. The healthcare professional taking the telephone or
verbal order will document “WRBO” for written read back order.
C.
Preprinted Orders when applicable, shall be completed in detail on the order sheet of the
patient's record, dated, signed and timed by the practitioner. All preprinted orders must
be approved the Forms Committee.
D.
All discharge orders for inpatients and observation patients shall be accompanied by
orders for discharge medications (or no medication). The discharge medication order
shall include name, dosage and frequency of all medications the patient is to take at
home. In addition, the discharge order shall include activity limitations, diet and follow-up
care instructions. It is mandatory that a discharge form, including reconciliation of
medication, be completed. "Same med" or other similar vague orders are not
appropriate and shall not be accepted.
Reports of Procedures, Tests and Their Results:
A.
Pertinent reports shall be recorded, dated and timed.
B.
Preliminary reports will not be placed on the chart with the following exceptions:
1. Echocardiograms preliminary reports.
2. Radiology preliminary reports.
3. Autopsy provisional reports
X.
Discharge Summary
A.
All patients placed to a bed, whether inpatient admission or observation, shall be
required to have a completed discharge summary on the medical record. House staff are
expected to complete the discharge summary the day the patient is discharged.
However, in anticipation of patient discharge or transfer to another facility, the discharge
summary may be dictated within 24 hours of the actual discharge from the facility. If the
patient’s hospitalization is extended beyond the expected discharge or there is a change
in patient status prior to the patient’s discharge, a discharge addendum will be required.
B.
Content of Discharge Summary:
1.
2.
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FINAL DIAGNOSIS which is the condition found to be responsible for the
admission.
Date of Admission and Discharge
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3.
4.
5.
6.
7.
8.
9.
10.
C.
XI.
Admitting Diagnosis or Chief complaint
History of present illness
Significant Findings
Hospital Course (include procedures performed, treatment rendered)
Complications, if any
Discharge instructions (include activity, diet and medications)
Condition on Discharge
Disposition (if transferred, state level of care the receiving facility will provide, i.e.,
rehab, acute care, psych, etc.)
A discharge summary shall be authenticated by the attending physician.
Authentication of Entries in Patient's Medical Record:
A. Clinical entries in the patient's record shall be accurately dated and authenticated.
Authentication means to establish authorship by written signature, identifiable initials or
computer key.
1.
XII.
Authentication of records post discharge will be accomplished utilizing electronic
signature.
B.
Telephone orders for DNR and Restraints must be authenticated and dated/timed by the
licensed physician within 24 hours. Telephone order must be signed, dated and timed
with 48 hours. All other orders must be authenticated and dated/timed within 48 hours
of patient discharge.
C.
The history and physical, operative reports, consultations, and discharge summaries
must be validated and countersigned by the appropriate staff physician within thirty days
of patient discharge.
D.
The use of a rubber signature stamp is prohibited.
E.
Electrocardiograms over-reads may be authenticated by the Cardiologist's typed name
only.
F.
If an ordering physician is unable to authenticate his/her verbal order (i.e. ordering
physician is off duty), it is acceptable for a covering physician to co-sign the verbal order
of the ordering physician. The signature indicates that the covering physician assumes
responsibility for his/her colleague’s orders as being complete, accurate and final.
Symbols and Abbreviations:
A. The use of abbreviations is limited and only standard abbreviations are to be considered
when documenting in any written notes or orders in the medical record.
B. The use of abbreviations in the medical record mist be viewed within the context of the
documentation, as many abbreviations are used for more than one item, e.g. RA for
rheumatoid arthritis or right atrium. When a definition of an abbreviation is in doubt, the
hospital relies on the following reference for guidance: Medical Abbreviations, Twelfth
Edition by Neil M. Davis.
C. When referring to items from the Periodic Table of Elements, the standard letter
designations are acceptable in the medical record. Additionally, chemical compounds
that are most often used may be written in their standard letter designations, e.g. KCl for
potassium chloride.
D. B. The following abbreviations/dose designations are NOT allowed during medication order
process:
Abbreviation/Dose
Designation
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Word or Phrase
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Intended Meaning/
Misinterpretation
Correction
All Apothecary
symbols
Examples:
dram
minim
AU
AS
AS
OU
OS
OD
Aurio uterque
(each ear) Left ear
Right ear
Both eyes
Left eye
Right eye
IU
International Units
U
Unit
Mistaken for 'IV'
intravenously
Mistaken as a zero (0)
g
MS
MSO4
MgSO4
microgram
Mistaken as 'mg' milligram
q.d. or Q.D.
XIII.
Use metric system
Morphine Sulfate
Morphine Sulfate
Magnesium Sulfate
Every day or
Once daily
q.o.d. or Q.O.D.
Every other day
qn
nightly or at
bedtime
Zero after decimal
point
(Trailing zero)
1.0 mg
Zero before
decimal dose
(Leading zero)
.5mg
symbol for dram misread
for “3”
ml
ou (oculo uterque- each
eye)
Mistaken for each other
Don't use these
abbreviation
Spell out :Both ears
Left ear
Right ear
Both eyes
Left eye
Right eye
Spell out units
Spell out the word
unit
Use mcg
M
Confused
for one another.
Write “morphine
sulfate” or
“magnesium sulfate”
Mistaken as q.i.d.,
especially if the period
after the “q” or the tail of
the “q” is misunderstood
as an “i.”
Misinterpreted as “q.d.”
(daily) or “q.i.d. (four times
daily) if the “o” is poorly
written.
Misinterpreted as “qh”
(every hour).
Write “daily”
Do NOT use a trailing zero
for doses expressed in
whole numbers.
One milligram mistaken as
ten milligrams when the
decimal is not seen
ALWAYS use a leading
zero before a decimal for
doses less than whole
number.
One-half milligram
mistaken as five milligram
1mg
Write “every other
day”
Use “nightly.”
0.5mg
Release of Medical Records:
A.
Records may be removed from the Hospital's jurisdiction and safekeeping only in
accordance with a court order, subpoena or statute. All records are the property of the
Hospital and shall not otherwise be taken away without permission of the Chief Executive
Officer or Hospital Compliance Officer.
B.
Unauthorized removal of records from the Hospital is grounds for suspension of the
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practitioner for a period to be determined by the Medical Policy Board.
XIV.
Alteration of Records: A single line shall be drawn through each line of inaccurate
material making certain that it is still legible. All deletions shall be marked "error", dated and
initialed. A correction shall be entered in chronological order making sure to indicate which
entry the correction is replacing. In any questionable situations, corrected notations shall be
witnessed by a colleague.
XV.
Removal of Material from Records:
A. Absolutely nothing shall be removed from the Medical Record except when
preliminary reports are replaced with final reports.
XVI.
Incomplete Medical Records:
A.
Medical Staff members will be suspended for failure to complete medical records within
the designated time. House staff will lose vacation days for failure to complete medical
records within the designated time. Every two weeks warning letters will be sent to
physicians as a reminder that they need to correct these deficiencies. If the records
remain incomplete for seven days after notice the suspension sequence is activated.
The practitioner’s CUMC identification badge will be suspended along with the
practitioner’s privilege to utilize the parking garage and medical staff lounge/dining room.
B. Failure to complete medical records for a second week will result in continued suspension
of a practitioner’s CUMC identification badge and will be expanded to include clinical
privileges and rights to admit or schedule patients for surgery, or to provide any other
professional services.
C. Failure to complete records for a third week will result in continued suspension of a
practitioner’s CUMC identification badge and clinical privileges and right to admit or
schedule patients for surgery, or to provide any other professional services. The Vice
President of Medical Affairs will be notified of the practitioner’s continued suspension.
(1) Delinquent records for house staff members will be re-assigned to the attending
physician for completion. Once the records has been referred to the attending
physician for completion it will not be reassigned to the responsible house staff
members. A letter will be sent to the house staff member’s Program Director outlining
their failure to complete their medical record responsibilities. Medical records left
incomplete by a house staff member due to illness, leave of absence or successful
completion of the program will be referred to the attending physician for completion,
but will not be reported to the Program Director.
D.
Failure to complete these records four weeks after the date ot suspension shall be
deemed a voluntary resignation of the practitioner's Medical Staff membership. A
practitioner whose clinical privileges are automatically suspended, or who have resigned
Medical Staff membership for failure to complete medical records, shall not be entitled to
procedural rights as set forth in the Policy on Appointment, Reappointment or Clinical
Privileges.
E.
Special Circumstance:
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(1)
Practitioners/mid-levels who are ill will not be placed on the overdue list if the
Health Information Department is notified.
(2)
Practitioners/mid-levels who are on vacation or out-of-town will not be placed on
the overdue list if the Health Information Department is notified advance. The
clock for record completion restarts when the physician returns.
(3)
House staff on rotation at other facilities will be expected to complete all record
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deficiencies on schedule.
(4)
When the Senior Vice President for Medical Affairs determines that extenuating
circumstances exist, a practitioner/s/mid-level’s records may be signed by his
partner or other members of his professional corporation.
E. Filing incomplete medical records
(1)
After 90 days from initial suspension, medical records which have not been
completed by the responsible Medical Staff members will be filed incomplete.
This will be done with the approval of the appropriate Department Chairperson.
A notation of the incomplete records will be made in the patient’s records and the
practitioner’s Medical Staff credentials file. Completion of these records will be
required prior to re-instatement of Medical Staff privileges.
XVII.
Video Tapes/Images: All non-diagnostic videotapes/images made for educational or research
purposes are the property of the Medical Staff member performing the procedure. The
Medical Staff member is responsible for the storage, retrieval and retention of the
videotapes/images in accordance with applicable State law.
REVIEWED AND APPROVED: June 23, 1980
First Revision: October 19, 1981
Second Revision: December 20, 1982
Third Revision: March 26, 1985
Fourth Revision: April 7, 1986
Fifth Revision: April 27, 1987
Sixth Revision: November 23, 1987
Seventh Revision: January 12, 1990
Eighth Revision: June 14, 1991
Ninth Revision: August 26, 1991
Tenth Revision: May 25, 1993
Eleventh Revision: November 14, 1993
Twelfth Revision: June 27, 1995
Thirteenth Revision: September 16, 1997
Fourteenth Revision: April 21, 1998
REVISED: Fifteenth Revision: March 21, 2000
Sixteenth Revision: May 20, 2001
Seventeenth Revision: May 15, 2003
Eighteenth Revision: August 19, 2003
Nineteenth Revision: December 17, 2003
Twentieth Revision: August 18, 2004
Twenty-first Revision: December 14, 2005
Twenty-second Revision: March 22. 2006
Twenty-third Revision: March 25, 2007
Twenty-fourth Revision: November 28, 2007
Twenty-fifth Revision: March 19, 2008
Twenty-sixth Revision: June 25, 2008
Twenty-seventh Revision: September 28, 2008
Medical Executive Committee
March 3, 2009
Date
President
Governing Board
March 25, 2009
Date
CEO
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