MARSHALLTOWN MEDICAL & SURGICAL CENTER
Marshalltown, Iowa
HEALTH INFORMATION MANAGEMENT POLICY & PROCEDURES
Policy Number: HIM 501
Subject:
Admission Card/Discharge Fax Notices
Purpose:
Prompt retrieval of available previous medical information needs to be accomplished to
provide to the health care team. HIM is notified in a variety of ways.
Materials:
Admit (Addressograph) cards
Computer MPI
Sign out Log
Sign out guides for permanent file
Archives key
In Box
Faxed Discharge Notices
Procedure:
A.
ADMISSION CARDS
1.
Check the In Basket frequently for new material.
2.
When admission cards are received, check the sign out log to see if the chart has been
checked out (excluding OB or Newborn admissions which are not signed out - cross off the
parent=s name on Newborn card and just file in In Box) . If the chart has not previously
been logged as signed out, sign the chart out using the process below.
OB cards (rooms starting with 1 - 108,116, etc. and OB service) - do not sign out old
charts - file in In Box.
Newborn (NB service) - cross off parent name and file in In Box
Highlight SNF names in yellow.
Highlight ICF (Service of X,G or H) with purple.
Note microfilm information on card and highlight in green.
3.
Look at each card to see if there have been previous hospitalizations by determining when
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HEALTH INFORMATION MANAGEMENT
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the medical record number was issued. The last new number issued the last time they
were checked will be noted in the Sign Out Log throughout the week. If the unit number
has been newly issued (number is larger than the one in the Sign Out Log), file the card.
4.
For previously issued numbers (“old”) check the Sign Out Log to see if the chart has
already been sent to the ER or unit. If so, file the card.
5.
If not already signed out, check visit history to see the date of the most recent visit filed in
the Medical Record; it will determine from where the chart will be retrieved. Services in
CPSI with a letter are filed in the medical record in HIM (exceptions - Z(Miscellaneous) and
x (Filmed Death chart).
6.
To check out an active or archived chart, complete the following information on a 3x5 card
with: Patient name, chart number, where the chart is going, complete date including year
and your initials. Place it in an outguide and:
a.
Determine the location of the chart (active or archives) If in the active files and
replace it with an outguide. If you are taking a volume chart, note which volume is
being taken, on the card. If the chart is in the Archives, retrieve the chart, but file
the outguide in the active files as the patient now has a current registration.
b.
Note the unit chart is to be taken on a sticky note and place on the chart folder
over the patient’s name.
c.
Check the folder contents against the visit information in MPI, looking for recent
incomplete in or out patient encounters (not necessary for Archive charts).
1)
Recent discharges may be circulating in an incomplete folder. If inpatient
records are missing, check the Incomplete Box for the location of the chart.
Write on the tracer card where the chart is being sent and the date. If a
chart you’re removing from a physician drawer needs dictation, please
follow the HIM 602 Charts Needing Dictation Notice to Return procedure.
2)
If an E, A, B, D, C2, B2, T2 visit, check the date and look on the
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HEALTH INFORMATION MANAGEMENT
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outpatient desk or Log to see where the record might be. When found,
make copies of incomplete records (at least if they haven't been coded yet,
if you're pressed for time) and send them in a 'Please Return to Medical
Records' folder; try to keep the original record in HIM for processing.
d.
Log the sign out in the book. Check the appropriate column(s) for the type(s) of
chart(s) being signed out (incomplete in and/or out, Active files, Archives) and
where the chart is being taken/sent.
7.
Hand deliver the chart to the appropriate area or Greeter escort may be called to take
charts to units when available.
8.
If the patient=s information is on microfilm, note the roll-blip number in the log, indicating
whether or not information was retrieved. Highlight microfilm information in green.
B.
FAX NOTICES
1.
Faxed Discharge/Transfer notices: If one indicates that the patient was discharged to a
nursing home, including our SCC unit, a report needs to be done in the MedRite system.
a.
On the Transcription Entry Screen, hit F2 for the list of originators/facilities. Type
in the beginning or the nursing home name (if not sure of name if abbreviated, call
the unit discharging the patient – do not assume you know which it is). If our
SCC, type in SCC. When the black carrot indicator is next to the correct line (you
can mouse click on it to highlight the name), click on the Select button in the top
right of the box.
b.
F2 when in the Patient Name field. Type in a portion of the patient’s name. Be
careful to select the right admission if there are multiple listings for the patient!
Match account number from the Addressograph on the fax notice, or admission
date. If there are two of the same account numbers listed for the same admit
date, choose the one that does NOT end in -E.
Once you have highlighted (click
on) the correct demographic listing, again click on Select.
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HEALTH INFORMATION MANAGEMENT
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c.
Alt W when you are in the Date field.
d.
Click back up on the Report Type ID field above Patient Name.
Backspace over
the report type in the field, and type in 071.
e.
F9 when the Transcription Entry Screen (TES) is completed. You will go into
document creation. If there is any special information to be entered, put it in the
Special Info prompt. Using Masterview (Shift F3), check to see if the summary has
already been transcribed. If it has, make sure that a copy of the summary gets to
the nursing home. Once you are done with the document, be sure to hit F9 to
finish. When a transcriptionist transcribes the summary, this information will be in
the system to indicate a copy needs to go to the nursing facility.
2.
When finished with the fax notice, note your initials next to the nursing home name for
MedRite entry on the notice. Place it in the holder on the shelf by the fax machine.
Originated by:
Health Information Management
Effective date:
10/03
Authorized by:
Health Information Management
Authorized by:
_________________________________________
HIM Director
Revision date:
Review date:
2/04, 5/04, 7/07, 5/08, 6/10
Date