Handwritten notes should be legible.
Documentation of a patient encounter should be timely, and all encounters should be dated and timed.
Admission H&Ps should be documented within 24 hours of admission. At a minimum, there must be a brief written admission note on admission.
Progress notes should be made daily on all inpatients.
Discharge summaries should be completed on discharge or within 24 hours.
Both PCMH and BSOM have electronic medical records.
The inpatient electronic record at PCMH is HealthSpan. Physicians use HealthSpan for writing orders, progress and procedure notes, accessing results (lab and imaging), and reading vital signs and nursing notes. We went live with HealthSpan at Pitt County Memorial Hospital in 2007 and continue to optimize the system. Other regional hospitals also use the system, and the medical school will go live with HealthSpan in 2009.
(formerly Logician—you will often hear people call it this) is the electronic medical record used by the medical school. Imaging and lab results as well as appointments and clinical encounters are all documented in this system.
You will learn how to use the electronic medical record systems during orientation.
HIPAA is the Health Insurance Portability and Accountability Act. It is a federal law that took effect April 13(14), 2003 and which legislates standards regarding patient privacy, electronic data information and the physical security of health care information. While this is a complex piece of legislation, is the element that will affect all of you the most. As those of you with experience in health care already know, protecting patient confidentiality is not something new, most of us have been doing it all along. The difference now is that it is mandated by the federal government.
Protected Health Information (PHI) pertains to any individually identifiable information involving the health status of a patient. PHI may be used for treatment, payment and hospital operations. Use of PHI for other purposes requires the patient’s authorization.
It is a requirement to audit our HIS (hospital information system) usage
March 17, 2009