ACCT NAME
SAINT LOUISE
REGIONAL HOSPITAL
LOCATION
9400 No Name Uno
Gilroy, CA 95020
URL
www.saintlouiseregionalhospital.org
------------------------------------------------------------------------------------------QUICKSHOT
Verbatim: Yes.
Patient Name: Replace dictated name with "the patient."
Allergies: BOLD AND ALL CAPS.
Headers: BOLD AND ALL CAPS.
Account Number Identifier: 007
Font: Courier New 11
-------------------------------------------------------------------------------------------ABBREVIATIONS
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
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.
--------------------------------------------------------------------------------------------
Account Specifics - SLRH
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ALLERGIES
Bold and all in caps.
ALLERGIES: THE PATIENT IS ALLERGIC TO PENICILLIN.
or
ALLERGIES: The patient is allergic to PENICILLIN.
or
ALLERGIES: PENICILLIN.
-------------------------------------------------------------------------------------------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 SLRH, you can send a report to the customer with 3 blanks or less unless it is a letter.
All letters should be reviewed for blanks, unless the blank is a doctor's name or other
proper noun/name that an editor is unlikely to know. This goes for all work types, proper
noun/name blanks or cut-off audio blanks that an editor is unlikely to known should not
be sent to editing. Send these blanks to the customer.
-------------------------------------------------------------------------------------------CARBON COPIES
Do not send a CC to a dictating Wound Care Clinic physician even if they request one.
All hospital dictating physicians can receive a CC to themselves if they request one.
-------------------------------------------------------------------------------------------DATA INPUT WINDOW
Data Input Window:
DATA INPUT WINDOW
Acusis Job Number
Customer Job Number
Customer
Work Type
Auto populated
Auto populated
Auto populated--do not change; alert techs if error
Correct the Work Type appropriately
Billing Number
Populated with ADT, which you select based on
dictated criteria and ADT match.
Medical Record Number
Last Name
Select ADT based on correct MRN or type in number
as dictated. The number will start with M.
As dictated
Account Specifics - SLRH
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First Name
As dictated
NPs and PAs to have attending physician; Add in
Attending tab
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
Auto populated
Auto populated
Admit Date
Do not use this field. Type this date in Service Date if
dictated.
Discharge Date
Do not use this field. Type this date in Service Date if
dictated.
Surgery Date
Do not use this field. Type this date in Service Date if
dictated.
Service Date
Enter Surgery Date, Visit Date or Consult Date as
dictated; if not dictated, leave blank
Date of Consult
Do not use this field. Type this date in Service Date if
dictated.
31
WORK TYPE
Transfer Summary
Preoperative History and
Physical
32
33
34
35
36
37
History and Physical
Consultation
Operative / Procedure Report
Discharge Summary
ER Dpt
Pulmonary Function Study
38
39
40
41
42
WCC History & Physical
WCC Consult
WCC Physician Progress Note
WCC Procedure Report
WCC Discharge Summary
30
SERVICE DATE
Date of Transfer
Date of Preop H&P. Could also be future
surgery date; use what is dictated.
Date of H&P. Could also be future surgery
date; use what is dictated.
Date of consultation.
Date of surgery.
Discharge date.
Date of encounter.
Date of encounter.
Date of H&P. Could also be future surgery
date; use what is dictated.
Date of consultation.
Date of visit/encounter.
Date of procedure.
Date of discharge.
SLRH wants us to use the following rule regarding dates:
 The doctors will dictate a Date of Service, Date of Consultation, Date of
Procedure, or Date of Surgery. Any date of service must be entered in the Service
Date field only. Do not use the other date fields in Data Input Window.
 We are to use the date that is dictated. If not dictated, SLRH wants us to leave the
Service Date field blank.
Account Specifics - SLRH
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 Discharge Summary dates: Please enter the discharge date in the Service Date
field.
 Preop H&P and H&P dates: This Service Date can be either the date of the actual
encounter (visit date) or it could be the planned surgery date. If a surgery date is
given, please use the surgery date in the Service Date field.
-------------------------------------------------------------------------------------------DATE OF SERVICE SELECTION CRITERIA
EXACT MATCH - You must only select an ADT that is the exact match for the
encounter of the patient. Ideally this will match the date given by the dictator. The
MRNO and patient information must match. If you do not have an exact match, set a
Doubt reason for No ADT.
A note about SLRH ADT: SLRH requires patients to go through an admitting process
prior to surgery, usually the day prior. Thus, often the admitting/available inpatient ADT
will be for the day prior to surgery dates. This is considered the match for this patient.
Inpatient work will only have one admitting date. Use this ADT, but be sure to change
the service date to match the dictator's instructions.
Also, ER patient's may frequently have ADT that is for the day before. For example, if
someone is seen late in the ER perhaps they are admitted at 11 p.m. and seen at 1 a.m.
the ADT may look a day earlier than what is being dictated. Please use your judgment in
these instances and select the correct ADT for the encounter.
See above below for ADT regarding Wound Care Center patients.
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.
WCC ADT
ADT for Wound Care Center patients: A patient will have the same account/billing
number for the entire calendar month. If they are seen the next month, the system at
Saint Louise will automatically discharge the patient and then create a new
account/billing number. Doctors should dictate the date of service.
Dates and Dr. Ronald Yanagihara – Per Acusis Standards Guide, all dates should be
spelled out for this account. (D: 01/01/09 T: January 1, 2009.) Dr. Yangihara wants his
reports strictly verbatim, including his dates. Therefore, for Dr. Yanagihara's reports
only, type the date as dictated.
Examples:
D: 01/01/09 T: 01/01/09
D: January 1, 2009 T: January 1, 2009
Account Specifics - SLRH
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-----------------------------------------------------------------------------------------HEADINGS & SUBHEADINGS
Paragraph headings are in BOLD AND CAPS.
For all reports, please type the paragraph headings as dictated. Use Templates/Normals
but amend them to reflect what is dictated. For example, you may change "Admitting
Diagnosis" to "Impression" if dictated that way.
The Discharge Summary and Transfer Summary have a required heading: Discharge
Diagnosis (or it could be Final Diagnosis). Either way, even if not dictated, this heading
must be included on the report.
On a Preop H&P, you should add the heading Date of Surgery at the top of the report
(before Chief Complaint), if dictated. Doctors Burt and Benninghoven often dictate this.
NOTE: ALL TEXT STARTS ONE SPACE AFTER THE HEADER AND ONLY
ONE SPACE AFTER, NOT TWO, NOT WITH A TAB.
In Review of Systems and Physical Exam, subheadings are in all caps and in a continuous
paragraph, not on left margin:
PHYSICAL EXAMINATION: VITAL SIGNS: On physical exam today,
BP 122/82, P 60, R 12, T 97.9, weight stable at 171 lb,
performance status 70%. GENERAL APPEARANCE: He is
nontoxic, but uncomfortable. HEENT: Anicteric. Pupils 3
mm, equal and reactive. Extraocular movements full.
Throat clear. Tongue midline. NECK: Supple without
goiter. Lymph nodes are not palpable at neck or
supraclavicular spaces. LUNGS: Clear to percussion and
auscultation. HEART: Regular without gallop or murmur.
ABDOMEN: Moderately distended. There is diffuse point
tenderness, but no rebound. EXTREMITIES: Without edema or
synovitis. NEURO: There are no neurological motor
deficits.
Diagnostic Data is always a separate section from Laboratory Data. Lab data are
chemical lab studies; diagnostic data are x-rays, CT, MRI, etc.
LABORATORY DATA: Lab studies today include WBC 12.4, RBC
2.8, hemoglobin 9.9, hematocrit 30, MCV 109, platelets 89.
On chemistry panel, potassium is 4.2, BUN 10, creatinine
0.9, CBG 114, albumin 3.6, globulins 2.8, total bilirubin
is 1.3, AST and ALT normal, alkaline phosphatase 512.
Account Specifics - SLRH
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DIAGNOSTIC DATA: Plain films are pending.
------------------------------------------------------------------------------------------VERBATIM
This account is a verbatim account. Pleased transcribe what is dictated as closely as
possible. Edit grammar, punctuation, spelling and similar dictation errors as necessary to
achieve clear communication. Likewise, edit slang words and phrases, 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 the
dictator's style. Editing which leads to rephrasing of the dictation or tampering with the
dictator's style is not allowed.
-----------------------------------------------------------------------------------------WORKTYPES
General Account
Work types:
30
31
32
33
34
35
36
37
Transfer Summary
Preoperative History and Physical
History and Physical
Consultation
Operative / Procedure Report
Discharge Summary
ER Department
Pulmonary Function Study
Wound Care Clinic
Work Types:
38
39
40
41
42
WCC History & Physical
WCC Consult
WCC Physician Progress Note
WCC Procedure Report
WCC Discharge Summary
TAT in hours
8
4
8
8
24
24
4
24
TAT in hours
4
8
8
24
24
Please be sure that the correct work type is entered for the WCC notes. Frequently these
are miscoded by the dictators, so please check every report. If you're not sure, please
send it to editing.
-----------------------------------------------------------------------------------------Account Specifics - SLRH
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HELPFUL HINTS
Spacing: Please make sure there are no extra carriage returns at the end of your
documents. The easiest way to check this is do a Control+End and make sure the cursor
is on the last line of the document, not below on a blank line.
The customer prefers only 1 space after the colon on paragraph headings.
-----------------------------------------------------------------------------------------------------------
Dr. Yanigahara is very particular about his dictations and wants them typed strictly
verbatim. Please take extra care with his reports.
------------------------------------------------------------------------------------------------------------
Emergency Department Reports:
Physician Assistants must have an attending co-sign their reports. They should dictate
who the attending is. They may also dictate the following statement at the end of the
report; please type it:
The patient was evaluated and treated under physicianapproved, diagnosis-specific protocols. The supervising
physician is [doctor's name], M.D.
I saw this patient under the direct supervision of
[doctor's name], M.D.
------------------------------------------------------------------------------------------------------------
Dr. Burt - Donald Burt Jr. dictates his reports AND an "Informed Consent" in the same
job. Please remember to type both parts of each job, creating a new template (report) for
the second job.
------------------------------------------------------------------------------------------------------------
Medications: 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.
------------------------------------------------------------------------------------------------------------
WCC Physicians
Scott Benninghoven, M.D. - General Surgery - WCC Medical Director
Jack Fisher, D.P.M. - Podiatry
Account Specifics - SLRH
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Bakri Musa, M.D. - General Surgery
Nang Nguyen, D.O. - General Surgery
Mohammed Qayyum, M.D. – Interventional Cardiology
------------------------------------------------------------------------------------------------------------
Discharge Summary Format Note:
DISCHARGE (or FINAL) DIAGNOSIS: This is required. Please type heading/title
even when not dictated and leave 3 spaces in between this and next paragraph. (This is 3
hard returns between this header and the next.)
Choose one header, DISCHARGE DIAGNOSIS or FINAL DIAGNOSIS, not both.
Refer to Discharge Summary Normal.
------------------------------------------------------------------------------------------------------------
Operative Note Instructions;
Surgeon: On operative notes in WordScript you must add the surgeon as the attending
via the Attending tab. There is no Surgeon field in Data Input Window, so we have
mapped for this customer the Attending physician tab/field to perform this function. Do
not add a header for the surgeon on the report, just use the Attending tab.
Dictating: Scott Benninghoven, M.D.
Surgeon: Scott Benninghoven, M.D.
Action: Add Scott Benninghoven, M.D. as attending physician via the Attending tab.
Assistant Surgeon: On operative notes in WordScript if an assistant surgeon is
named you must add an ASSISTANT SURGEON: header and that physician's name to
the top of the report.
ASSISTANT SURGEON:
John Smith, M.D.
This is temporary until we can get another field created or mapped for this header.
8.26.09 ach
Account Specifics - SLRH
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