ACCT NAME
SUTTER COAST HOSPITAL
LOCATION
800 East Washington Boulevard
Crescent City, CA 95531
URL
www.suttercoast.org
------------------------------------------------------------------------------------------QUICKSHOT
Verbatim: Yes
Patient Name: Yes, except for Pelican Bay patients.
Allergies: Bold and all caps.
Headers: Bold and all caps - text on same line.
Account Number Identifier: 008
Font: Courier New 12
*CDFS (headers, subheaders, etc.) accomplishes formatting requirements if
used. If typing manually—not using CDFS headers, subheaders, etc.—you
will be responsible for formatting.
-------------------------------------------------------------------------------------------As SUCO is a CDFS account, the responsibility is yours to ensure the
final customer copy is formatted correctly using the headers, subheaders,
and other CDFS functions prior to sending your report to the customer. Use
the Preview function in CDFS to view the final customer copy of your
document. If any changes are needed, be sure to recheck the document prior
to sending.
-------------------------------------------------------------------------------------------ABBREVIATIONS
The Institute for Safe Medication Practices (ISMP) is devoted entirely to medication error
prevention and safe medication use. They provide the medical industry with safe
guidelines pertaining to medication use and dosing. Please refer to the ISMP Dangerous
Abbreviations list (Do Not Use List of Dangerous Abbreviations on our Intranet) and
apply these guidelines to your transcription for this customer.
Common abbreviations and acronyms are acceptable on this account and are to be
transcribed as dictated unless in the DIAGNOSIS and PLAN sections. In this case they
are to be spelled out, with the exception of very common abbreviations such as lab
values, CT, MRI, CMV PCR, etc. If you are doing a procedure note work type if
following the PROCEDURE header the actual procedure name is what is abbreviated
Account Specifics - Sutter Coast
1
then it would be spelled out. For example, ORIF would be open reduction, internal
fixation while MRI-guided biopsy would not be spelled out. Do not guess at an
abbreviation that has more than one meaning. For example, if ALL is dictated only in the
diagnosis and nowhere else in the report clarifies whether it is acute lymphoblastic
leukemia or acute lymphocytic leukemia then it is okay to leave it ALL in the diagnosis.
If you spell out the uncommon or not easily recognizable abbreviation please add the
abbreviation or acronym following it in parentheses.
-------------------------------------------------------------------------------------------ALLERGIES
The header will be in bold and caps and the
allergy/allergies will be in bold and all caps:
ALLERGIES: She is allergic to PENICILLIN.
CDFS instructions for allergies.
1. Insert Alt+5 header for allergies.
2. Type allergies.
3. Highlight specific name of allergy.
4. Invoke Alt+9 command to format text of allergy.
Account Specifics - Sutter Coast
2
5. Select BOLD UPPERCASE from bookmark menu. Click OK.
6. Formatted allergies will look like this:
In CDFS document:
On Preview (customer copy):
-------------------------------------------------------------------------------------------BLANKS IN FILE
A blank is inserted with the Alt+B command. Do not make notes in the report about
what it might be. Use the Has blank(s) Doubt reason. Do not guess at
words/phrases/unfamiliar terminology.
For Sutter Coast, you can send a report to the customer with 3 blanks or less.
As for all accounts, do not send STATs to editing. Do not flag STATs with doubt
reasons unless approved by a supervisor.
--------------------------------------------------------------------------------------------
Account Specifics - Sutter Coast
3
CARBON COPIES
To add CCs for Sutter Coast you will use the Insert Physician Info box, available under
the drop-down menu under Job Manager. See WSWE Training Manual for detailed
instructions.
-------------------------------------------------------------------------------------------DATA INPUT WINDOW
DATA INPUT WINDOW
Acusis Job Number
Customer Job Number
Customer
Work Type
Billing Number
Medical Record Number
Last Name
First Name
Auto populated
Auto populated
Auto populated--do not change; alert techs if error
Correct the Work Type appropriately
Populated with ADT, which you select based on
dictated criteria and ADT match.
Select ADT based on correct MRN or type in number
as dictated.
As dictated
As dictated
NPs and PAs to have attending physician; add
ATTENDING PHYSICIAN or SUPERVISING
PHYSICIAN header to report as dictated.
Auto populated. Correct in Data Input if needed. If
unknown, leave blank and send to editing with a note.
Dictating Physician
Dictating Physician ID#
Dictate PhyID Copy
Admit Date
Discharge Date
Service Date
Auto populated
Auto populated
As dictated or match ADT Admit Date if within 24
hours of dictation date. If not match, use dictation date.
As dictated or leave blank
Enter Surgery Date, Visit Date or Consult Date as
dictated; if not dictated use Admit Date from ADT if
within 24 hours. If no ADT match and not dictated, use
dictation date.
-------------------------------------------------------------------------------------------DATE OF SERVICE SELECTION CRITERIA
EXACT MATCH - You must only select an ADT that is the same date of service as
given by the dictating physician. The MRNO and patient information must match. If
you do not have an exact match, set a Doubt reason for No ADT.
Account Specifics - Sutter Coast
4
Please do a manual search if no ADT automatically populates upon opening the job. You
can search by any/all of the criteria available on this page. You can also search partial
names or values by clicking the checkbox next to that field. Click on Search to execute
search function.
IF ATTENDING PHYSICIAN IS NOT THE DICTATING PHYSICIAN: When a
resident, P.A. or nurse is dictating you must add a header of ATTENDING PHYSICIAN:
or SUPERVISING PHYSICIAN: (whichever is dictated) and add physician's name.
This differs from other WS customers in that we do not use the Attending Physician
option in the Data Input window for this customer at this time.
If the dictating is the attending physician, do not add a header of ATTENDING
PHYSICIAN or SUPERVISING PHYSICIAN to the report; that information is entered
in post-processing.
Dates: Use the date of service dictated. If no date is specifically dictated you may use
the date noted in the ADT if it is the correct match for the report. If no date is dictated
and the date of service is unknown you can use the date of dictation.
1
WORK TYPE
History and Physical
2
Operative Note
3
Consult
4
Discharge Summary
5
Emergency Room Record
6
Echocardiogram
7
Epidural
8
Treadmill Stress Test
10
Preop H&P
11
Delivery Note
14
Addendum
Account Specifics - Sutter Coast
SERVICE DATE FIELD
SHOULD SHOW
Admit Date
Surgery date as dictated or default to
ADT date if ADT match.
Consult date as dictated or default to
ADT date if ADT match.
Discharge date as dictated or default
to ADT date if ADT match.
Visit date as dictated or default to
ADT date if ADT match.
Visit date as dictated or default to
ADT date if ADT match.
Visit date as dictated or default to
ADT date if ADT match.
Visit date as dictated or default to
ADT date if ADT match.
This is the date the patient was
given the preop. However, if future
surgery/admit date is given, use that
date.
Visit date as dictated or default to
ADT date if ADT match.
Visit date as dictated or default to
ADT date if ADT match.
ALSO USE DATE FIELD
FOR
Admit Date
Discharge Date, Admit Date
Admit Date
*Note: Always CC
referring/primary when one is
mentioned.
Admit Date
5
15
Pediatric Cardiology
Report
17
Orthopedic Note
18
Progress Note
20
Transfer Summary
21
Emergency Room
Admission
22
23
Procedure note
Death Summary
24
Holter Monitor
Visit date as dictated or default to
ADT date if ADT match.
Visit date as dictated or default to
ADT date if ADT match.
Visit date as dictated or default to
ADT date if ADT match.
Date of transfer or date as dictated
or default to ADT date if ADT
match.
Visit date as dictated or default to
ADT date if ADT match.
Surgery date as dictated or default to
ADT date if ADT match.
Date of death, as dictated.
Service date as dictated or default to
ADT date if ADT match..
Discharge Date, Admit Date
*Note: Always CC
referring/primary when one is
mentioned.
Admit Date
Discharge Date
-----------------------------------------------------------------------------------------HEADINGS & SUBHEADINGS
Paragraph headings are in BOLD AND ALL CAPS. Text begins on the same line.
CDFS will format headers in bold and caps when you use the Alt+5 headers.
 If you use the existing headers in the Alt+5 header command, just select that header
entry. You do not need to add a colon after the header.
 Please use the CDFS Alt+5 headers for SUCO. If you do not use Alt+5, the bold and
caps properties typed manually will not be formatted correctly on the customer copy.
You may type them manually, but must be sure to tag them (Alt+9) and make sure they
are in BOLD CAPS.
Do not add a header for ATTENDING PHYSICIAN if the dictator is the attending; this
information is entered in post-processing.
DO add a header to the report of ATTENDING PHYSICIAN or SUPERVISING
PHYSICIAN if dictated and the dictator is not the attending.
Do not add date headers; this information is entered in post-processing. Enter dates in
date fields in Data Input Window as noted above. *Exception: DO add a DATE OF
BIRTH header to a report if this information is dictated.*
Account Specifics - Sutter Coast
6
In Review of Systems and Physical Exam, subheadings are in
all caps, not bold, and on the left margin:
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 39.2, pulse 179, respirations 50.
GENERAL: Alert and active. Good eye contact.
NECK: Moving neck freely.
EYES: Both eyes are injected with a slight amount of
purulent discharge.
EARS: Tympanic membranes normal.
NOSE: Rhinorrhea.
THROAT: Clear.
CHEST: Scattered rhonchi and wheezes throughout both
lungs. Slight retractions. Breath 50 times per minute.
ABDOMEN: Soft. No masses palpable.
EXTREMITIES: All extremities move well.
SKIN: Clear. No rashes.
When medications with dosages are given, please transcribe them in a numbered list. If
no dosage are given list format is still preferred, but paragraph form is acceptable if
dictated that way.
------------------------------------------------------------------------------------------PATIENT NAME
In body of report it is okay to use the patient name if dictated EXCEPT FOR:
Residents of Pelican Bay State Prison are seen as patients at Sutter Coast Hospital. For
these patients, a different protocol is used when filling out the patient name. Instead of
the patient's name, the doctors will dictate CDC followed by an inmate identifier
comprised of an alpha character followed by a number. In this case, the patient's last
name will be listed as CDC, and the patient's first name will be the alpha character
followed by the number: CDC, A12345 The patient's name should not be dictated, but if
it is, replace the patient's name with above protocol and do not type patient's name into
the body of the report.
-------------------------------------------------------------------------------------------VERBATIM
This account is a verbatim account. This pertains to content. Please transcribe what is
dictated as closely as possible, while also following Acusis Standards Guide guidelines
and customer account instructions. Edit grammar, punctuation, spelling and similar
dictation errors as necessary to achieve clear communication. Likewise, edit slang,
English or medical inconsistencies and inaccurate phrasing of laboratory data. Do not
transcribe contractions; always spell out contractions when dictated. Do not abbreviate
medications or use slang medication names; always transcribe the complete brand-name
or generic name of the medication. Do not tamper with the meaning of the report or with
Account Specifics - Sutter Coast
7
the dictator's style. Editing which leads to rephrasing of the dictation or tampering with
the dictator's style is not allowed.
SLANG
Slang in our common vernacular should be avoided. Words or phrases such as ain't,
comin, goin, or gonna, etc., should be transcribed in their correct forms. Type
abbreviation and acronyms as allowed per customer account instructions and the ASG.
See the paragraph pertaining to medical jargon below regarding common medical
"slang".
MEDICAL JARGON
In the current SR environment, medical terminology slang, or medical jargon, has
become subjective. Rather than spend precious time editing neuro to neurologic or sed
rate to sedimentation rate, consider what will be understandable to the average reader.
We would like to edit as little as possible with regard to slang in an effort to maintain
productivity, and sometimes the speech engine will insert something different than
verbatim text based on "learning" and other parameters.
For example: In laboratory findings:
D: Labs sed rate 12 mm/hr.
T: LABS: Sed rate 12 mm/hr. Or LABORATORY: Sedimentation rate 12 mm/hr. (or
some combination of either)
Solution: As both are clearly understandable to the reader, both are acceptable.
Exceptions:
1. Never use slang for medications. Always type the complete, accurate medication
name (generic or branded).
2. Never use street or English slang; eg., ain't, comin, gonna, etc.
3. Never use slang for proper nouns/names of surgical equipment, disease or
syndromes, etc.
4. Never use slang for obscure, unfamiliar slang terms. If you think it out of place
per the specialty of your report or something that would be unfamiliar to the
common reader, please use the correct form of the word or phrase.
5. Do not confuse slang with abbreviations, acronyms, or other acceptable short
forms of words allowable.
------------------------------------------------------------------------------------------
WORK TYPES
Work types:
Work type #
History and Physical
Operative Report
Account Specifics - Sutter Coast
01
02
TAT in hours
8
24
8
Consultation
Discharge Summary
Emergency Room Record
03
04
05
8
24
8
*Note: Always CC referring/primary when one is mentioned.
Echocardiogram
Epidural
Treadmill Stress Test
Preop History and Physical
Delivery Note
Addendum
Pediatric Cardiology Report
RHC Orthopedic Clinic
Progress Note
Rural Health Clinic Report
Transfer Summary
Emergency Room Admission
06
07
08
10
11
14
15
17
18
19
20
21
24
24
24
4
24
24
24
24
24
24
2
4
stat
stat
stat
*Note: Always CC referring/primary when one is mentioned.
Procedure Note
Death Summary
Holter Monitor
22
23
24
24
24
24
Any work type can be STAT – turnaround time is 2 hours.
-----------------------------------------------------------------------------------------HELPFUL HINTS
EMERGENCY ROOM REPORTS
Always CC the referring/primary medical doctor (or primary care physician) when one is
mentioned in the report. Insert the CC even when not specifically dictated to CC. The
customer wants all PMDs CC on WT 05 and 21 reports.
OPERATIVE REPORTS
Date of Operation and Surgeon's name are put in automatically at top of report. Do not
add these to your reports. Please remove the heading "Assistant" if no assistant is
mentioned.
Sutter Coast Hospital does not have anesthesiologists; they use Certified Registered
Nurse Anesthetists - CRNAs. Therefore, the "Anesthesiologist" heading is not included
as operative report heading in autotext. However, if a doctor dictates a CRNA as the
Anesthesiologist, please include this information in the report.
Note: Dr. David Cink never wants "Anesthesiologist" on his operative reports.
Account Specifics - Sutter Coast
9
Doctors' standard operative reports can also be found in Normals.
-------------------------------------------------------------------------------------------Dr. Polidore will state PPH which stands for Procedure for Prolapsing Hemorrhoids.
Surgeon Tien Nguyen ID #483 is pronounced Winn or Gwinn.
Many Locum Tenens are often used for surgery, Hospitalist, OB/GYN
Hospitalist Hassan Sheikho, sees the majority of our patients. He also goes by Sam.
-------------------------------------------------------------------------------------------Terms unique to Sutter Coast Hospital in Crescent City, California, which are often
misspelled:
Crescent City is located in Del Norte County with surrounding towns of:
Fort Dick
Gasquet
Hiouchi
Klamath
Orick
Brookings Harbor
Brookings
Physicians/Health Care Providers in the area without hospital privileges:
Kelly Lowther
Robert Petzold
Pamela Demian
James Norland
Jitendra Patel
Ellen Winger
Heidi Carlson
Kathryn Wood
John Biteman
JoAnn Vipond
Bruce Franz, DPM John Fjerstad, DPM
Our patients are transferred to:
Rogue Valley Medical Center
Mad River Community Hospital
Crescent City Convalescent Hospital
Addie Meedom House
Oceanic Meadows
Chetco Inn Residential Care Facility
St Joseph Hospital
Providence Hospital
Sempervirens
Curry Good Samaritan Center
Park View Special Care Center
Macklyn House
Del Norte Community Health Center is also known as the "A" Street Clinic.
Pelican Bay State Prison
-------------------------------------------------------------------------------------------DR. SYLVIA NASH INCOMPLETE REPORTS: If you get a report by Dr.
Nash that is cut off it needs to be sent with a doubt reason. Others: Dr. Nash cut-off
report.
Account Specifics - Sutter Coast
10
DR. SYLVIA NASH ADDENDA: If you get a report by Dr. Nash that is the
continuation of a cut-off report it needs to be sent with a doubt reason. (She will usually
state she was previously cut off and is continuing.) Others: Dr. Nash cut-off report. If
the report is just a run-of-the-mill addendum send it to the customer.
9/20/10ach
Account Specifics - Sutter Coast
11