Him Official Policies & Procedures Binder

Department-Specific Scope of Service/Staffing Guidelines............................................................
3
Organizational Chart........................................................................................................................7
Vacation Scheduling........................................................................................................................8
DEPARTMENTAL EMERGENCY MANAGEMENT PLAN......................................................9
Retention of Patient Records.........................................................................................................17
Security of Patient Records............................................................................................................19
Modification of Dictations by Physician Office............................................................................20
Dictation Instructions.....................................................................................................................21
STAT Dictation: 2 Hours Transcribing Time.......................................................................22
Processing Transcribed Reports.....................................................................................................23
Accessing Medical Records...........................................................................................................25
Chart Assembly..............................................................................................................................27
Clinic Record Processing...............................................................................................................30
Color Coded Numbering System...................................................................................................32
Legibility of Medical Records.......................................................................................................35
List of Reports................................................................................................................................37
Loose Report Filing Procedure......................................................................................................39
Medical Record Chart Request .....................................................................................................40
Medical Record Forms Development, Approval and Control Policy............................................41
Merging Medical Record Numbers...............................................................................................46
Notification of Incomplete/ Delinquent Records...........................................................................47
Quantitative Analysis.....................................................................................................................51
Re-Analysis of Patient Records for Completion............................................................................56
Reports for Signature/ Completion................................................................................................58
Running Reports............................................................................................................................59
Unit Patient Record........................................................................................................................61
Acute Medical/Surgical Care Chart Order.....................................................................................62
Acute Medical/Surgical Care Chart Order (Block Format)...........................................................65
Acute Rehabilitation (Rehab) Center Chart Order.........................................................................70
Ambulatory Treatment Center Chart Order...................................................................................72
Come and Go Unit (CGU) Chart Order.........................................................................................73
.......................................................................................................................................................73
Emergency Services Chart Order...................................................................................................76
Psychiatric Chart Order..................................................................................................................77
Psychiatric Assessment..................................................................................................................79
Skilled Nursing Facility (SNF) Chart Order..................................................................................80
Transplant (Organ) Donor Chart Order.........................................................................................82
After Hours Access to Medical records Stored Outside of the Health Information Management
Services Department......................................................................................................................83
Hospital Security Personnel...........................................................................................................84
Hospital Based Clinics...................................................................................................................84
CONFIDENTIALITY AGREEMENT..........................................................................................87
Authorization Requirements for Uses and Disclosure of PHI.......................................................88
Patient Confidentiality, Use and Disclosure of protected Patient Health Information (PHI)........90
Release of Medical, Psychiatric, alcohol/substance Abuse and HIV Information........................93
Incoming and Outgoing Mail.........................................................................................................97
1
Ordering Supplies..........................................................................................................................99
Problems with Work Equipment, Office Furniture, Work Area..................................................107
Administrative Closure of Incomplete Medical Records.............................................................108
Declaration of Complete Medical Record...................................................................................111
Abbreviations and Symbols.........................................................................................................112
2
Department-Specific Scope of Service/Staffing Guidelines
Health Information Department
APPROVED BY: Barbara Farris, RHIT, CCS
PURPOSE: To outline the scope of service for the Health Information Management
Department
POLICY:
I. SCOPE OF SERVICES
DESCRIPTION OF SERVICES PROVIDED

i. Services include assembly, abstracting, analysis, and coding of patient
discharge data, transcription of dictated reports, data reporting, storage and
retrieval of medical records, cancer tracking, and release of information.
Further, the department facilitates the ongoing review of the completion,
accuracy and timely delivery of the medical records.
HOURS OF OPERATION
1. Open to hospital staff: Monday-Friday, 7:00 a.m.-11:00 p.m.;
Saturday, 8:30 a.m.-5:00 p.m.; Sunday 8:30 a.m.-5:00 p.m.
2. Open to the public: Monday-Friday, 8:00am – 5:00pm.
B. CUSTOMER OR POPULATION SERVED
1. The department provides services to medical staff, nursing units,

clinical departments, patients and their families, hospital
administration, and regulatory agencies.
PROCEDURE:
II. METHODS USED TO ASSESS AND MEET THE QUALITY NEEDS OF THE
HOSPITAL
Refer to the Performance Improvement Plan

III. QUALIFICATIONS AND RESPONSIBILITIES OF STAFF
TITLE QUALIFICATIONS RESPONSIBILITIES

Director • Refer to Job Description • Refer to Job Description
Coding • Refer to Job Description • Refer to Job Description
Supervisor
Medical • Refer to Job Description • Refer to Job Description
3
Record
Technician
Intermediate • Refer to Job Descriptions • Refer to Job Descriptions
Clerk II
(7.5 FTE’s)
Incomplete • Refer to Job Description • Refer to Job Description
Record
Coordinator
Release of • Refer to Job Description • Refer to Job Description
Information
Coordinator
Cancer • Refer to Job Description • Refer to Job Description
Registry
Coordinator
Cancer • Refer to Job Description • Refer to Job Description
Registry
Analyst
4
STAFFING
A. MINIMUM STAFFING PATTERN

The department is staffed as follows:
Title FTE Shift Days

Manager, Health Information Services 1 Day Mon-Fri
Coding Supervisor 1 Day Mon-Fri
Medical Record Technician 2.5 Day Mon-Fri
Release of Information Coordinator 1 Day Mon-Fri
Incomplete Record Coordinator 1 Day Mon-Fri
Intermediate Clerk (AT) 1 Day Mon-Fri
Intermediate Clerk (JE) 1 Day Tues-Sat
Intermediate Clerk (DB) 1 Day Mon-Fri
Intermediate Clerk (CC) 1 Day Sun-Thurs
Intermediate Clerk (DG) 1 Day Mon-Fri
Intermediate Clerk (TC) 1 Day Mon-Fri
Intermediate Clerk (MF) 1 Night Mon-Fri
Intermediate Clerk (AW) O.5 Night Mon-Fri
Cancer Registry Coordinator 1 Day Mon-Fri
Cancer Registry Analyst 0.5 Day Mon-Fri
B. CRITERIA USED TO ADJUST STAFFING LEVELS Fluctuations in the

volume of inpatient discharges, ambulatory care and emergency room visits.
C. PROVISION OF STAFFING DUE TO UNEXPECTED INCREASE IN

NEED:
Staffing is generally fixed. The department utilizes outside coding and clerical
services on occasion to assure adequate staffing levels.
D. DELEGATION OF DEPARTMENT OPERATIONS TO ANOTHER

DEPARTMENT:
The nursing supervisor is responsible for retrieval of records for patient care
during non-operating hours.
RECOGNIZED STANDARDS
 JCAHO
 California Health and Safety Codes
 CMS Regulations
 All department-specific standards
5
 California State Law
 United States Federal Laws and Statutes
VI. DEPARTMENT GOALS
•To provide support to departments and functions in order to maintain and assure that the
quality of care delivered to our patients, and the administrative functions of the
medical center meet the standards set by regulatory agencies.
•To support the hospital’s revenue cycle and facilitate timely record completion through
prompt and accurate processing and coding of medical records.
VII. DEPARTMENT PERFORMANCE IMPROVEMENT
The goal of Performance Improvement activities is to enhance existing processes and

outcomes and then continue to improve. Performance improvement activities at Saint
Francis Memorial Hospital are consistent with the commitment of the medical center to
provide the highest quality, comprehensive care to the people served. Improving quality of
care is accomplished by identifying those issues that are high risk, high volume, problem
prone, and high cost related to the care and services provided. Performance monitoring, and
improvement activity processes are prioritized and based on aggregated and analyzed data.
Outcomes are consistently evaluated to assess effectiveness and provide feedback for
improving care.
Saint Francis Memorial Hospital supports and encourages a multidisciplinary approach to

quality. All departments are actively involved in service line and/or functional quality
activities. Data is collected in a systematic and consistent process to assure data integrity.
Data is analyzed and action plans are developed to assure goals are met and maintained.
6
Organizational Chart
Saint Francis Memorial Hospital
Health Information Management Services
APPROVED BY: Barbara Farris, RHIT, CCS
HIM Director
Barbara Farris, MS, RHIT,
CCS
Department Supervisor
Vacant (1.0)
Cancer Registry Inpatient & Rehab Coder
Jessica Johnson Chart Pulls/ Chart Refiles/
Clerical Function Back-Up Vacant (1.0)
Cancer Registry Ted Clendennen (1.0)
Jessica Johnsoon (1.0) OPS Coder
Analysis/ MR # Merges/ Deborah Myers (.6)
Reception/ Chart Pick-Up/ Assembly ER Coder
Discharge Processing of Diana Garcia (1.0) Carmen Martinez (1.0)
Charts
Denise Brooks (.5) Re-analysis and Suspension
Joan Clark-Rebollini (1.0) Release of Information
Coordinator
Loose Material/ EWR Chart Assembly/ After Hours Christina Lee (1.0)
Final Processing Reception (P.M.) Shift
Cathy Chow (1.0) Montell Fong (1.0)
Transcription Coordinator Release of Information

Jessica Contreras 1.0)
Josephine Estrella (1.0)
7
Vacation Scheduling
Health Information Management
POLICY: The staff will complete and submit a schedule time-off request to the manager
within an appropriate time frame. Vacations will be approved according to seniority, first come,
first serve basis and job classification.
PURPOSE: To provide guidelines for the process of scheduled time-off requests and ensure
equity in the approval of vacation time within the Health Information Management office.
PROCEDURE:
1. Complete and submit a scheduled time-off request by the employee to the manager within an
appropriate time-frame
Guidelines for submission of request

a. One/ two days= two weeks advance notice
b. One week= one moth’s advance notice
c. Over one week= over one month’s advance notice
2. Review and approve accordingly by the manager within a week from the receipt of request
Guidelines for approval
a. by seniority
b. by first come, first serve basis
c. by job classification
Note: No two employees can be on vacation at the same time.

3. Write the approved dates for scheduled time-off of each employee on the vacation calendar
by the manager
4. Write on the board by the employee
o Name
o PTO
o Dates
8
DEPARTMENTAL EMERGENCY MANAGEMENT PLAN
Designated Department Emergency Coordinator:
Bobbi Farris - Director, Health Information Management Department
DEPARTMENTAL ROLES AND RESPONSIBLITIES
Approved By: ____________________________________ Date: ______________

(Departmental Manager)
Approved By: Bobbi Farris Date: April 9, 2009
(Manager/ Director)
Level I: A situation occurs that overwhelms immediate in house resources and results in
redeployment of resources such as: county MCI – Red Alert, localized haz mat spill, patient
volume exceeds capacity (staffing or physical space) e.g. ED Diversion.
List your Departmental responsibilities here:
1) Provide emergency medical record retrieval
2) Provide support to registration staff in assignment of medical record numbers
3) Staff report to Command Post/Center for additional assignments
Level II: Any event that MAY result in a large number of patients that will require hospital-
wide mobilization in order to continue to provide care to existing inpatients and incoming patients.
This would be as a result of a moderate to severe single site emergency (e.g., a major BART
accident) or multiple small MCI’s (e.g. a Loma Prieta-type earthquake).

1) Access damage to department and report if necessary
2) Ensure safety of staff
3) Ensure safety of medical records
7) Initiate fan out list if necessary
Level III: Any event that WILL result in enough damage and casualties to require an extensive,
coordinated response to minimize morbidity, mortality and human suffering at SFMH. Citywide, this would
only be as a result of a devastating earthquake that reduces many sections of the City to rubble, disrupts
normal City systems, and results in a large number of casualties over a widespread area. However, a Level
III may be declared at SFMH (e.g., a severe explosion or widespread fire in our Main Building).
1) Access damage to department and report if necessary
2) Ensure safety of staff
3) Initiate Fan Out list
4) Ensure safety of medical records
9
Staff Assignments
1) Assess any damage to 1. Assess your department using the Department

persons, computers and Operating Status Report
medical records
2) Able bodied person ____ Designate one person
coordinates communication in the department to account for all
among staff members and patients, staff, and visitors.
with Director about ____ Clear hallways and potential
equipment, staffing, evacuation routes.
department damage
3) Report staff availability to What to Do Next:
Command Center 2. Review your departmental
4) Able bodied representative plan NOW.
reports to Command Center ____ Make assignments and
for assignment implement your departmental plan at
5) Repair/clean any obvious a level directed by Incident
damage Command Center.
6) Respond to requests for
____ Complete Unit
medical records as needed
Operating Status Report and deliver
to the Incident Command Center.
Follow all instructions from
the Incident Command Center
____ Activate your

Departmental Personnel Call-Back
List only when instructed to do so
by the Incident Command Center.
What to Do for an Internal Disaster:

1. Follow all instructions above.
2. Complete status and deliver to Incident
Command whether or not your department is
affected.
3. If your department does not appear to be
affected, continue routine operations unless
otherwise instructed by the Incident
Command Center.
What to Do in the Event of a Fire:
Rescue - persons who are in immediate danger
Alarm - pull alarm box on unit AND dial 9-911 to
call the San Francisco Fire Department
Contain - close all doors and windows to avoid
drafts that could spread the fire.
Extinguish - only if you have been trained, feel it is
safe, AND you have a way out!
10
What to Do in the Event of a Hazardous Spill:
In Case Evacuation Is Ordered: Roles of Other Departments

The SFMH Evacuation Plan is located in the Disaster Manual.
It contains general evacuation information A. Incident Command Center is
and instructions for evacuating a patient care area. established in Weyerhaeuser to provide
overall direction and coordination of
Unless there is an extreme and obvious emergency that hospital operations.
requires immediate evacuation to prevent the imminent loss
of life, any employee who becomes aware of any situation that
could result in the evacuation of any port of SFMH must
immediately notify the CNE or designee by operator page.
REMEMBER, unless there is an extreme and obvious
emergency that requires immediate evacuation to prevent
the imminent loss of life, do not evacuate unless ordered by
the Incident Command Center.
A copy of your Departmental Evacuation Map (also located in all

stairwells and elevators) should be located the Disaster Manual.
This map shows the location of all fire alarm pull boxes,
fire extinguishers, fire hoses, evacuation routes, and stairwells.
What to Do During an Earthquake:

• Do not try to exit the building. Advise patients,
staff, and visitors to do the same.
• Take shelter if possible. Get under a sturdy table
or desk.
• Move away from windows that might break and
any tall carts or shelves that might topple and fall
on you.
• Watch for falling objects such as wall-mounted equipment,
heavy books, lights, and/or ceiling tiles.
What to Do After an Earthquake:

• Follow all instructions on the opposite page.
• Proceed carefully. Floor may be covered with broken glass,
water, sewage, and/or hazardous materials.
• Clear hallways. Remove all carts, chairs, wheelchairs, and
other items that may block the hallways in the event of an
earthquake and/or slow passage in the event of an aftershock.
• Move patients away from windows. Pull curtains to protect
from flying glass.
• Be careful opening cupboards and closets—things may
fall out.
• Prepare for aftershocks. Remove heavy items from tall
shelves and place on the floor. Secure all hazardous materials
11
and/or breakable containers. Lock all drawers, cabinets, and
filing cabinets. Set locks on all rolling carts and beds.
PRE-DISASTER DEPARTMENTAL ROLES AND RESPONSIBILITES
Planning and Mitigation Responsibilities of the Departmental Manager

(add department specific activities below):
 Develop a Departmental Plan that includes departmental roles and responsibilities, evacuation routes,
and a current Personnel Fan Out Telephone List.
 Train all staff on departmental response in the event of a Level I, II, or III internal or external disaster.
 Train all staff on how to evacuate the department.
 Participate in disaster exercises, or evaluate actual events in which the Emergency Response plan is
activated, at least twice a year.
 Assure that departmental non-structural hazard mitigation has been completed.
Location of Basic Emergency Supplies:
Item Quantity Location Check Frequency Responsible

Person
Fire Extinguisher 1 1. On wall Monthly Engineering
adjacent
to perm
files
(terminal digits
00)
First Aid Kit 3 2 in HIM supply Quarterly Denise Brooks
cabinet
1 in basement
file areas
Flashlights Many Front Desk Quarterly Denise Brooks
Director’s
Offices
Employee Desks
1st Floor File
Room
Basement File
Room
Batteries Many Front Desk Monthly Denise Brooks
Director’s Office
Employee Desks
Radio/ TV N/A TV located in N/A N/A
MD lounge
Departmental Personnel Recall Fan Out List is located in Section 2 of the Emergency
Management Manual. All staff should maintain a current copy at home. Do not recall
staff unless instructed to do so by the Incident Command Center.
12
Requirement to Report to Work: Employees are required to report to work in the event
of a disaster. Listen to KCBS (740 AM), KNBR (680 AM), or KGO (810 AM) for
specific instructions of when and where to report.
Recovery Activities: As soon as feasible, departmental services should be restored in

order to fulfill SFMH’s mission to deliver humanistic, cost-effective and culturally
competent health services to patients,staff and physicians through:

 Maintain record security and safety
 Assist physician and nursing as needed
 Activate fan out
 Report to Labor Pool
13
Disaster Plan for Saving Hospital Records
POLICY: Health information Management Services is responsible for implementing the

disaster plan for saving hospital records from result of a major natural disaster, such as flood,
fire, earthquake and other hazards.
PURPOSE: .To ensure the safety of all hospital records in the event of a natural disaster.
PROCEDURE:
A. Internal Disaster
1. Secure permission from authorities before entering the building to ensure the
safety of that area.
2. Have Engineering shut off al gas, electricity and water if these may pose a danger
3. Evaluate the damage done to the records
a. by fire
b. by water
4. Perform the following for water-damaged records

a. Decrease the temperature in the areas to slow the development of mold
b. Install fans in areas where there are water-damaged records
c. Remove and store records in a clean, dry, safe and well-lighted area
(Note: If possible store in walk in freezer spaces)
d. Photocopy Record (Note: It is less expensive to photocopy records than
it is to restore burned pr water-soaked records)
e. Contact Source Corp for service on salvaging fire-damaged records
and/or restoring water-damaged records
o will send a customer service representative within an appropriate
time frame to assess the damage
o develop a recovery plan
o photocopy record
o freeze-drying of water damaged records at approximately $75/
cubic feet
o implement the recovery plan
5. Perform the following for fire damaged records
a. Remove and store records in clean, dry, safe and well-lighted areas
b. Records that have been signed or burned along the edges can have the
burned portion removed wit a paper cutter and can be placed in new
folders
c. Photocopy the original record, where record has been more damaged but
is legible
14
d. Contact Source Corp for service on salvaging fire-damaged records and/
or restoring water-damaged records
B. Outside Storage
1. Please refer to the outside storage disaster plan for saving hospital records.
15
Locating Medical Record Numbers during Downtime
Health Information Management Services
POLICY: It is the policy of the Health Information Management Department to ensure that
correct medical record numbers can be identified during clinical information (Lastword) system
downtime.
PURPOSE: To provide guidelines for locating the medical record number of a patient during
clinical information system (Lastword) downtime.
PROCEDURE:
1. During downtime of the clinical information system, medical record numbers of

patients may be found in Anacomp CD located in the Department Director’s
Office
2. Insert the Anacomp CD with the latest creation date
3. Login user name: CHW password: SMSF
4. On the first screen select “Quick Search”
5. Refer to the attached screen prints for the remaining instructions
16
Retention of Patient Records
POLICY: Patient records are maintained in the original paper form for ten years or until the
patient has reached 19 years of age, whichever is longer after discharge or visit. Records older
than 10 years, excluding the records of minors who have not reached the age of 19 may be
destroyed. Four years of the most recent medical records are stored at the hospital. The
remaining six years of records are stored at an off site storage facility (SourceCorp). Patient
records are ordered from the off-site storage facility (SourceCorp).
PROCEDURE:
A. LOCATION OF RECORDS: The inpatient and outpatient records are stored by year in the
specific location by terminal digit or alphabetical order.
INPATIENTS Year Location
2008-2009 Health Information Management- 1st floor
2006-2007 Basement Storage
2005 & before Offsite storage- stored at Deliverex
Note: All inpatient records are in unit folders and filed in terminal digit order by year of last
activity
OUTPATIENTS (Emergency Room, Sports Medicine, Spine Clinic)

2008-2009 Health Information Management
2006-2007 Basement storage
2005-before Offsite storage- stored at Deliverex
Note: Ambulatory Surgery Records are stored the same as inpatients, Physical therapy
records are stored in the Physical therapy dept. For Outpatient Chemotherapy/ Blood
Transfusions, active records are stored on the 10th floor-nursing unit. Inactive records are
filed in the unit record in the central record system in terminal digit order.
B. Ordering records from Off-site Storage
o Complete the fax order form

o Fax to off-site storage at (415) 550-1029
o Order records accordingly to delivery schedule
o Days: Monday-Friday; Cut off time: 7:30am delivery Time: Before 11 a.m.
o Cut off time: 11:30 am Delivery Time: before 3 p.m.
o Order records on a STAT basis for patient care as needed
o Check-out LASTWORD
o Deliver or call for pickup
C. Returning Records to Off-site storage
o Place on shelf for returning to off-site storage

o Place records in storage box
17
o Notify off-site storage for pickup
D. Purging Of Records From Department By Off-Site Staff’
o Call off-site storage company for a time to purge oldest year from: basement file
room; department to basement file room
o Place records in boxes for off-site storage by the company
o Move the oldest year from the department to the basement file room
E. Purging of records from the Clinics
o Purge records for filing in a unit record in the centralized record system
F. Destruction of Records
o Pull records older than 10 years from the last visit of destruction by off-site storage
company at the beginning of each calendar year.
-retrieve the discharge lists for that particular year

-make a list of patients who have not yet reached the age of 19
-send the list to off-site storage company
-pull the records on the list for further storage
-send a confirmation letter with new location by the off-site storage company
o Send a written authorization for destruction of patient records by the HIM service
Manager
o Destroy the patient records by the off-site storage company

o Mail a certificate of destruction by the offsite storage company
18
Security of Patient Records
POLICY: The patient medical record is the property for the health care institution and is
maintained for the benefit of the patient, the medical staff and the hospital. The patient records
should not be removed from the hospital (to a location other than off site storage) without a court
order or subpoena. Patient records shall be stored in secure areas accessible only to authorized
personnel.
PROCEDURE:
o Patient records housed within the hospital shall be kept in secure areas at all times.
Patient records shall not be left unattended in areas accessible to unauthorized
individuals.
o Patient records in HIM, basement storage room, clinics and outside storage shall be
secured in such a manner to safeguard the records from fire, water loss, defacement,
tempering or usage by unauthorized persons.
o Patient records are legal documents that are subject to the rules of confidentiality. (See
policy for Release for Information, Patient Access and Subpoena)
o All employees who have access to information systems must sign a confidentiality
statement (network Usage Policy acknowledgement)
o Proper access to information systems will be achieved through password protection and
security levels.
19
Modification of Dictations by Physician Office
PURPOSE: Saint Francis Memorial Hospital (SFMH) has adopted the following procedure to assist
Physicians with transcription specialists in processing of dictations. Physician groups/offices that utilize
Transcription Specialists to review and update physician dictations to ensure the accuracy and
completeness before signature by responsible physician will utilize the following procedure once granted
privileges by Health Information Management and the Cerner/CareConnect Team.
PROCEDURE:
1. Posted dictation will be routed via Cerner/CareConnect to the appropriate inboxes of the
Transcription Specialist , P.A. (when applicable) and the dictating physician.
2. Prior to electronic signature by M.D./P.A. the Transcription Specialist may update the dictations.
3. Once completed, dictations are then (automatically) removed from the Transcription Specialists
inbox and are available for review and signature by the M.D. and the P.A. when applicable.
4. Dictations signed by the M.D. and the P.A. (when applicable) are not available for update by the
Transcription Specialist. These dictations will be marked as completed by the Transcription
Specialist and removed from the Transcription Specialists inbox by HIM.
5. Responsibility for accuracy of dictation content is that of the dictating physician.
6. See Processing Transcribed Dictations Policy for medical staff dictation procedure.
20
Dictation Instructions
Saint Francis Memorial Hospital
DICTATION INSTRUCTIONS
1. TO ACCESS THE DICTATION SYSTEM

OUTSIDE THE HOSPITAL: Dial: (888) 716-7024
 INSIDE THE HOSPITAL: Dial : *55
2. WAIT for System Greeting. You may interrupt and override system
prompts at any time.
3. ENTER your 5 DIGIT PHYSICIAN ID NUMBER _______ followed by #.
4. ENTER WORK TYPE followed by #.
5. ENTER THE 8 DIGIT MEDICAL RECORD NUMBER followed by #.
6. PRESS 2 to BEGIN DICTATING.
7. DICTATE your full NAME (and spelling); TYPE OF REPORT; PATIENT
NAME (and spelling); and MEDICAL RECORD NUMBER.
8. PRESS 8 if dictating multiple reports and RETURN to step 4.
9. PRESS 5 to complete dictation session. The job confirmation number will
be given for your records after pressing either 8 or 5.
WORK TYPES
1 - PRE-OP History & Physical 8- ER – PATIENT ADMITTED

2 - History & Physical 9 - ER – Patient Discharged
3 - TRANSFER SUMMARY 11 - Riese Affidavit
4 - Consultation Report 12 - Psychiatric Admit Note
5 - Operative Report 14 - Other Reports
6 - Discharge Summary 15 - Procedure Report
7 - Diagnostic Cardiology/Neurology 16 – Letter
WORKTYPES FOR HOSPITALIST USE ONLY

23 – History & Physical Exam 24 – Discharge Summary
25 – Transfer Summary
STAT DICTATION
Dictating physician MUST CALL 800- 747-6264 with the
21
dictation job number immediately following dictation.
Dictation cannot be processed as a STAT unless this number
is called
STAT Dictation: 2 Hours Transcribing Time
TOUCH TONE CONTROLS – While Dictating
1 - Hold 7 - Backup & press 3 to playback

2 - Record/Stop 8 - End Job
3 - Short Rewind 44 - Move to end
4 - Fast Forward 77 - Rewind to Beginning of Dictation
00 - Discard Dictation
FOR ASSISTANCE CALL: MedQuist: (800) 747-6264 OR

HIM Dept: (415) 353-6670
22
Processing Transcribed Reports
POLICY: The transcribed reports shall be process on a daily basis. The outside transcription
service transmits reports for automatic printing every hour on a daily basis. The copy of reports
will print in a bath at 4 p.m. on a daily basis.
PURPOSE: To provide guidelines on the process of transcribing reports and to ensure

education on the process of transcribing reports in the Health Information Management office.
PROCEDURE:
A. Outside Transcription Services
1. Transcribe
2. Proofread
3. Transmit
B. Health Information Management Service
1. Retrieve the printed transcribed reports from the printer

2. Retrieve the transmission log
a. match the reports to the list
b. make a check mark
c. edit the reports
d. print/ follow- up on missing reports
3. Retrieve the batch copy of reports at 4 p.m.
o physicians e.g. dictation physician, carbon copy to the physician(s)

4. Sort the reports into batches
a. copies for mailing

b. original report into in-house record (binder)
o Note/ verify room number on the report
d. Original history & physical for next day surgery of future admission
o Check surgery schedule for Come and Go Unit and inpatient
surgeries
o Check the printed Pre-admit Report for Ambulatory Treatment
Center
e. Original report auto print to Cardiology/ Neurology as of 11/20/2000
1. Med Quist
o Echocardiogram
o Holter monitoring
23
o Persantine-thallium stress test
o Non-invasive vascular lab report
o Treadmill/ stress echocardiogram
5. Deliver the original reports

a. Nursing floors
o Punch holes accordingly

o Insert into proper section of the patient’s record on the nursing
floor
o Place in the basket in CGU for next day surgery or future
admission
b. Emergency Services Professional Billing Services
o Netfax
c. PFS
o Med Quist access
d. CGU
o Med Quist access
6. Place the copies of the report in the outgoing mail tray for delivery/ mailing by
the mailroom
o Physicians
o Other hospitals
o Sort and deliver by mailroom personnel
7. Sort and mail the copies of the report by outside copy service
a. Prepare envelope
o Name
o Address
b. Insert and seal copies of the report in to the prepared envelope

c. Place in the outgoing mail tray for pick up by the mailroom
24
Accessing Medical Records
POLICY: It is the policy of the Saint Francis Memorial Hospital's Health Information
Management Department to retrieve medical records as needed.
PURPOSE: To provide guidelines for locating the medical record number of a patient during
clinical information system (Lastword0 downtime.
PROCEDURE:
1. Patient visit history should be researched as follows:

A. Visits post 1999: MS4
B. Visits post-CareConnect Go-Live: MS4
C. Visits prior to 1999: Lastword
2. Medical records for Inpatients, ER's, C&G's, and ATC's are primarily electronic records
which can be accessed electronically on CareConnect. A portion of these medical records
are paper such as progress notes, patient consents and other forms.
3. Outpatient Clinic medical records are not electronic. The following clinic records are
maintained in the clinics until discharge or until later at which point they are filed in the
Health Information Management Department:
A. Sports Medicine Clinic (SF): Maintained by Sports Medicine during treatment period.
After termination of treatment, filed in separate volume and filed with the unit medical
record
B. Sports Medicine Clinic ( Walnut Creek) Records permanently maintained by the
Walnut Creek Clinic.
C. Sports Medicine Clinic - Corte Madera: Records permanently maintained by the Corte
Madera Clinic.
D. Spine Clinic: Maintained by Spine Clinic during treatment. After termination of
treatment, filed in separate volume and filed in the Spine Clinic section of the HIM file
room.
E. Wound Clinic: Filed in the Wound Clinic until discharge. Records then filed in
separate volume and filed with the unit medical record in the HIM Department.
F. Burn Clinic: Filed in the Burn Clinic until discharge. Records then filed in separate
volume and filed with the unit medical record in the HIM Department.
G. Franciscan Treatment Room: Records maintained by the FTR during active treatment.
Records are then transferred to the FTR section of the HIM file room.
H. Hyperbaric Oxygen Clinic: Records are permanently maintained by the Hyperbaric
Oxygen Clinic.
I. Total Joint Center: Records are permanently maintained by the Total Joint Center.
25
J. Cardiopulmonary Clinic: Maintained by Cardiopulmonary during treatment. After
termination of treatment filed in separate volume and filed with the unit medical record.
K. Outpatient Chemotherapy Clinic: Maintained by Chemotherapy clinic during treatment.
After termination of treatment, filed in separate volume and filed with the unit medical
record
L. Outpatient Rehabilitation Clinic: Records are permanently maintained by the
Rehabilitation Clinic.
M. Radiation Oncology Clinic: Records are permanently maintained by the Radiation
Oncology Clinic.
4. The location of paper medical records should be tracked when they are removed from
permanent file. The HIM department uses two tracking systems as follows:
A. Patients with visits in the CareConnect system: Track in the CareConnect Tracking
module. Refer to CareConnect Tracking instructions.
B. Patients with no visits in the CareConnect system: (NOTE: these are patients with no
discharges occurring on or after November 7, 2008.) Track the location of these
medical records in the LastWord system. Refer to Lastword Tracking Instructions.
26
Chart Assembly
POLICY: All inpatient and outpatient discharge records shall be retrieved from each of the
nursing units/ departments, assembled in the proper chart order, and filed on the analysis shelf
for further processing on the evening of discharge of the morning after the discharge.
Records for patients who are transferred from or to acute skilled nursing facility, rehab, or
psychiatric units in the hospital shall be retrieved, assembled and delivered to the appropriate
unite immediately so that the record is available for further patient care.
PURPOSE: To ensure proper chart assembly, filing, and analysis.
PROCEDURE:
5. Print a daily discharge/ admit roster for inpatient/ ambulatory, emergency and observation
from LASTWORD
o Click on the MR Report & MRADTREP
o Enter report number= 21: Discharge Registry by Name, 2: Observation Roster
by Name, 3: Ambulatory roster by name, 4: ED Log, and 12 1IP & Amb
Admits by Name
o Enter start date OD= Today, -ID= Yesterday
o Enter report end date
o Hold right click on mouse in printer location
o Double left click on St. Francis (+)- Printer
o Scroll and select printer
o Double click on selected printer
o Hit enter or click OK
6. Take the lists and cart to the nursing units and emergency department
7. Retrieve the inpatient and outpatient discharge record from the CCU, 7th, ICB, 3rd Floors &
CGU; and from the cabinet located in the emergency department.
8. Retrieve ancillary reports
i. match and insert reports into the retrieved record

ii. put the unmatched reports into the for filing basket
iii. retrieve MDS Sheets from the 9th floor
9. Locate and retrieve any and all old records
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i. nursing units
ii. emergency room
iii. HIM Services
Note: the old records are in alphabetic order in the cabinet/ drawer
iv. Deliverex
10. Insert the discharge record into the old record

11. Bring the records down into the old department
12. Place a red check mark on the list for each of the retrieval record
13. Verify in LASTWORD
A. Double check medical record number
B. Previous hospitalizations
14. Check-in the record in LASTWORD
o Click on MR location/ MRL

o Enter 6: receive Record in function
o Click OK
o Default of RIS in receiving department record type
o Enter medical record number and volume or scan in with bar code reader hit enter or
click OK
15. Make new folder for new patient
i. place the appropriate and correct labels

1. advance directive if applicable
2. color code/ number (refer to Color Code Numbering System Policy
and Procedure)
3. year band
4. confidential patient information for psychiatric records
5. confidential patient information See California AB408 and 488 for
HIV
6. Create volume bar code label
i. Click on MR location/ MRL in LASTWORD
ii. Enter 7: create volume
iii. Click OK
iv. Enter volume number for the corresponding account
v. Enter Y for bar code
vi. Hit enter
ii. make additional volume (s) if applicable
16. Assemble the record in the proper chart order and date order
i. Assure that each sheet belongs to the same patient
ii. Assure that there are no missing parts (thinned record)
iii. Assure that the discharge record is in the correct patient record folder
28
iv. Avoid overloading the record
1. not: leave about one inch free on the prongs
v. Use appropriate admission dividers with the type of admission and

year i.e. IP, CGU, ER, ATC, Psych Assessment, Sports Medicine,
Spine Clinic with the date (MMDDYYYY)
vi. Place the assembled record on the prongs in the patient record folder
i. Discharge record on the right side
ii. Advance directive on the left side
17. Maintain the patient record folder

i. Make an new folder for tom folders
ii. Replace labels, color code number, number, year band
iii. Update year scale
iv. Update volume (s)
-volume # at St. Mary’s
v. make a new bar code label for changed name and write aka
14. Place the records on the analysis/ coding/ abstracting shelf in terminal digit order
a. inpatient
b. come and go unit/ ambulatory treatment center/ psychiatrics
assessment
c. in-house folder for psychiatric assessment
18. Place the emergency room records in the basket for processing
19. Deliver the record for the transferred patient to the appropriate unit
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Clinic Record Processing
POLICY:
Health Information Management will pull old records for Clinics within 24 hours of
the request and will make new folders within 36 hours of admission to the clinic or
the request. The clinics will pick up the requested records.
Clinic records will be included in a unit record.
PURPOSE: To provide guideline for the process of clinic record processing.
PROCEDURE:
The following clinic records are processed by HIM staff:
• Sports Medicine
• Spine Clinic
• Wound / Burn Clinic
• Pulmonary Clinic
• Chemotherapy Clinic
II. Processing Sports Medicine Clinic Charts -

a. Sports Medicine charts are requested by Sports Medicine using
the "Sport Medicine Chart Request Log".
b. Locate the old record in LastWord or Care Connect using
Patient Tracking.
c. Pull the clinic record only.
d. Order records from off-site storage.
e. Create a clinic UR in Care Connect if this is the first visit since
Care Connect go-live.
f. Print labels for the new clinic URs.
g. Place MR number labels and year labels on the charts.
h. Refer to Color Coded Numbering System Policy and
Procedure.
i. Place contents in the patient record folder on the prong on the
right side.
j. Note the type of clinic on the file folder.
k. If the chart is to return to the clinic, sign the clinic UR out to
the clinic in Care Connect Patient Tracking.
l. Track clinic UR charts to the permanent file if the clinic is done with
the record.
m. File the Sports Medicine Request Log in the binder.
n. Place a rubber band around the stack of records.
o. Place appropriate cover sheet on top of the records
30
p. Leave on the counter for pick up by the clinic.
q.
III. Processing Other Clinic Charts -
a. Follow Steps II-d through II-l above.

b. Route the chart to permanent file as appropriate. (Refer to Accessing Medical Records P&P
for permanent file locations.)
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Color Coded Numbering System
Health information Management
POLICY: The following color-coded numbering system shall be utilized in making new
folders.
PURPOSE: To organize patient information based on medical record number, provide a

visual guide for the terminal digit filing system, and to ensure correct assembly of medical record
charts.
PROCEDURE:
Make a new folder using the following color-coded numbers according to the assigned medical
record number
a. tietary (two) digits from right to left, or top to bottom
b. middle (two) digits from right to left or bottom to top
32
c. primary (two) digits from right to left or bottom to top
d. facility code from right to left or bottom to top

a. 01= St. Francis
02= St. Mary’s
10= New Patient to St. Francis and St Mary’s
90= System Downtime
33
2. Place the color-coded numbering labels on the side of the folder vertically
3. Print a bar code label from LASTWORD
4. Place label on the front of the record at the top of the folder horizontally
5. Place the correct year band on the side of the folder vertically at the right top
6. Check the appropriate volume in front of the folder (if applicable)
a. not the volume# at St. Mary’s
7. Place appropriate labels (if applicable)
a. advance directives
b. confidential patient information
c. Sports Medicine
34
Legibility of Medical Records
POLICY: It is the policy of St. Francis Memorial Hospital that any illegible document shall
be determined by the following procedure. A document that is illegible, or very difficult/
impossible to read by two professionals due to the entry being poorly written or printed.
PURPOSE: To define “illegible documentation” in a medical record, to provide framework

for hospital and medical staff in determining legibility of all documentation in the medical record
by all care providers, and to establish the mechanism for review of relevant information from the
ongoing medical record review process and pharmacy interventions addressing illegible entries.
This policy is applicable to all healthcare documentation within the medical record
including nursing notes, progress notes, consultation records, physician orders, treatment
records, etc.
Definitions: Pharmacy Interventions: Process by which pharmacists initiate a phone call/

contact with the prescribing practitioner to clarify a medication order.
PROCEDURE:
A. Medical Record Review

1. As per the Medical Record Review policy and calendar, a random
selection of retrospective and concurrent medical records will be
reviewed by a multidisciplinary team.
2. Legibility will be included as an indicator during the review of each
medical record.
3. Aggregate data will be presented to Your Hospital Committee along
with any appropriate action plans. This data will include legibility
results.
B. Pharmacy Interventions
1. Pharmacy interventions will be recorded, aggregated, analyzed, and
appropriate action plans established.
2. Aggregated reports from pharmacy interventions will be reported to
Your Hospital Committee.
C. Illegible Medication and Procedure Orders
1. Medication orders that are illegible, unclear, or incompletely written
will not be carried out until clarified in writing, until it is rewritten
2. The individual who wrote the original order will be contacted. If

he/she is not available, then the covering practitioner will be contacted.
3. Medication errors that result from an illegible order shall be reports

using the (describe your occurrence screen/ incident reporting format
here) and forwarded to Risk Management
35
4. Unresolved legibility issues with physicians and allied health
professionals shall be reported to the respective (department chair/
committee)
References:
Comprehensive Action Manual for Hospitals (200)
Institute for Safe Medication Practice (ISMP) Quarterly action Agenda
Institute for Safe Medication Practice Whitepaper on Electronic Prescribing 2000
American Society of Health-System Pharmacists (ASHP)
36
List of Reports
POLICY:
PURPOSE: To provide a guideline for the Health Information management department on

the procedure of locating lists of reports.
PROCEDURE:
Clintrak Reports
A. Standard-template Report
Report Type: Management Report
Name: Coder Productivity
Records De-finalized
Records Finalized
Report Type: Patient Chart

Report Name: Discharge Report
1. Enter discharge dates ______to______
2. Edit list for patient type
Note: Patient type I= inpatient, P= psychiatric, R= rehab, S= SNF

Medical records Statistics monthly for reporting to QA/ I quarterly
B. Custom-template / pre-defined reports
Report Type: Administrative
Report Name: CMI Report by Finalized
1. Enter YTD 07/01/98 to 03/31/99
2. Hit Enter
3. Edit list on patient type
a. Six different reports
i. IPRX
ii. IPR
iii. I
iv. P
v. R
vi. X
4. high-light code e.g.: I
5. Click on >= add code to list
6. Click Ok
7. Enter current month 03/01/99
Note: Fax by the 3rd of each month
C. Report Type: Mortality

Report Name: Donor Log
37
1. enter discharge dates ____to____
2. Edit list for patient type (IPXR)
LASTWORD Reports
A. MRCREP- Completion Records

a. Note: Incomplete and delinquent medical records
i. Report No.:
MD Suspension Records
2: MD’s on suspension, sorted by MD name
27: Summary of delinquencies
Miscellaneous Reports
6: Provider’s Record incomplete 14 days
Detailed Letters
21: Incomplete Records by Responsible Physician
B. Patient Information
a. Click on CNS= census
b. Enter location= 3rd floor for psychiatric assessment
=9th for CHAMP

C. MRADTREP-ADT and Management Reports
Report No.:
Rosters
2: Observation Roster by Name
3: Ambulatory Roster by Name
4: ED Log
Note: print up on Fridays for each
Discharge reports:
21: Discharge Register by Name
25: Medicare Discharges by Name
38
Loose Report Filing Procedure
POLICY: All loose reports will be sorted and filed into the medical record within five days of
receipt. This will provide a uniform manner of filing within loose reports into the medical record
to ensure complete medical record.
PURPOSE: To ensure efficiency in the process of filing loose reports and to provide a
uniform manner in filing loose reports.
PROCEDURE:
1. An initial sort is done by reviewing all documents and separating them into
piles according to patient service type.
a. Inpatient
b. Come and Go Unit
c. Ambulatory Treatment Center
d. Emergency Room
e. Outpatient
2. If the date of service/ discharge date is on the loose report, the piles are then
sorted into service piles by their service date/ discharge dates
3. Reports that do not have a medical record number or service date/ discharge
date are researched in MPI
4. Reports are then distributed to their appropriate location for filing within the
designated location of the patient’s medical record
39
Medical Record Chart Request
POLICY: The am, pm, and weekend HIM clerks are to screen for previous admissions and
will monitor MR Chart Request on at least an hourly basis. Any “old” records will be pulled and
delivered to the nursing unites for patient care as soon as they are available (immediately when
located in hospital files, within 24 hours if located at DELIVEREX)
PURPOSE: To provide a guideline for the process of requesting medical record chart
requests, and to ensure efficiency when filling requests for medical charts.
PROCEDURE:
1. MR Chart Request forms print on LASTWORD printer in the reception area as

patients are being admitted. Take the notices from the printer at least hourly.
2. Enter MR# on LASTWORD screen and click on MPI to check for previous records.
Determine the existence of a previous record as follows:
a. Determine year of last inpatient or CGU/ ATC admit. Generally records are
filed in that year
b. If no inpatient admissions are indicated, check outpatient visits, ER, Come
and Go, Sports Medicine, Spine Center, and FTR. Records are kept in MR
system. The HIM Department does not keep records for other clinics.
o If there is not previous record, HIM Staff responds back to indicate

there are no previous records.
o If a previous record exists, return to HIM screen and review chart

location. Determine where the chart is located. Is it located on the
patient unit? If yes, inform the respected nursing unit.
o If the chart is not on the unit, pull the medical record and deliver to
the respected hospital location.
40
Medical Record Forms Development, Approval and Control Policy
POLICY: Saint Francis Memorial Hospital has established a Forms Committee to review,
approve and monitor all forms to be included in the patient’s legal, permanent medical record in
accordance with the forms design standards and guidelines set forth in this document. These
standards and guidelines are implemented to ensure uniformity within the permanent, legal
medical record in both paper based and electronic/imaged formats.
The Forms Committee has the responsibility for defining standards for form layout, format,
identification and duplication. The committee establishes and maintains oversight for medical
forms standards compliance.
FORMS COMMITTEE GOALS:
• To ensure that forms maintained in the permanent, legal medical record (paper-based,
electronic and imaged) are appropriate for patient care, risk management, financial
administration, teaching and research.
• To provide guidance to forms users as to what forms are considered part of the patient’s
medical record.
• To ensure that all forms meet the requirements of the Joint Commission, California state
statutes and federal laws and regulations governing documentation.
• To reduce the duplication of information in the permanent, legal health record through
consolidation of forms.
• To improve the level of communication among health care providers by ensuring a
minimum set of data elements be included in every permanent, legal medical record
whether maintained in a paper-based, electronic or imaged format.
DEFINITIONS:
FORM – Any printed, typed, or electronic document with blank spaces for insertion of required
or requested information (handwritten or electronically generated) that is made a part of a
patient’s permanent, legal medical record.
FORM OWNER/OWNER/SPONSOR – Individual who requests the production of a new or

revised form. The form owner/owner/sponsor is responsible for completing all necessary
paperwork in accordance with the forms approval process and follows the form through the
approval process and ultimately to implementation. The form owner/owner/sponsor has the
responsibility of distributing the form(s) to the necessary locations within and external to Saint
Francis Memorial Hospital and ensures that the obsolete versions of the same form have been
removed from use.
41
PROCEDURE (New Forms):
1. The form owner/sponsor will complete the Request For New or Revised Form
(Exhibit A) and submit it to the Director of the Health Information Management
Department along with an electronic copy of the form to be approved.
It will be required that the form will have been pre-approved by all the necessary
Users and departments prior to being presented to Forms Committee for final
approval
2. The form owner/sponsor will be contacted by a Forms Committee representative who

will schedule the owner/sponsor to attend an upcoming Forms Committee meeting to
present the form.
NOTE: The Forms Committee meets monthly to review forms submissions.

Form owner/sponsors must be in attendance to present the form and answer
questions regarding the form and its usage.
3. Forms owner/sponsors will need to ensure the following for all forms entering the
approval process:
• Form is in compliance with hospital approved and unapproved abbreviation lists

or otherwise spell out abbreviations on the form. If necessary an abbreviation
key may be placed on the form for reference.
• Define use of the form and indicate form needs in terms of layout and special
instructions for reproduction by the Forms Vendor.
4. Forms Committee will review all forms as scheduled to be presented and move to
either approve the form as is or make recommendations for change.
• If recommendations for change are requested to be made, the form
owner/sponsor will make the necessary revisions and resubmit the revised
version electronically to the Director of Health Information Management.
5. Once approved, forms will be assigned a form number by the forms vendor Tully-
Wihr. Form owner/sponsors will be advised (via e-mail) of the form number and its
availability for use at that time.
NOTE: All forms must be ordered through the forms vendor-Tully-Wihr.

The copying of forms by users on copy machines or by any other means is
strictly prohibited.
42
6. The form owner/sponsor will be responsible for distributing the form(s) to the
necessary locations within and/or external to Saint Francis Memorial Hospital and
ensures that the obsolete versions of the same form have been removed from use.
PROCEDURE (Revising Existing Forms):
1. Form owner/sponsor must request the most updated electronic form currently on file from
the HIM Department.
2. Form owner/sponsor will make revisions as needed electronically and resubmit the form
electronically to the HIM Department. The Director of the HIM Department will assess
the revisions to determine if the further review by the Forms Committee is necessary. If
so, form owner/sponsor will be asked to attend an upcoming meeting to present the
revised form for approval of the revisions.
3. For revisions made to generic templates which are used by multiple areas to specifically
customize a form to their clinic/patient care area, the Forms Committee will notify all
affected areas that a change has been made to the master and it will be the form
owner/sponsor’s responsibility to revise the form so that it matches the revisions made to
the generic template.
4. Revision date will be entered in the bottom left hand corner of the form after the form
number.
5. The form owner/sponsor will be responsible for distributing the form to the necessary
locations within and external to Saint Francis Memorial Hospital and ensure that the
obsolete versions of the same form have been removed from use.
FORMS LIBRARY
The HIM Department will maintain the following information on file:

•Hard copy and final electronic versions of all forms
• Correspondence/special instructions from the form owner/sponsor regarding the
form
• All versions of forms that have been revised
• Completed “Forms Approval” form
• Spreadsheet of forms available for ordering
FORM SPECIFICATIONS
The following form specifications must be adhered to when developing new forms for approval:
Page Set-Up
Upper left hand corner (header):
• Saint Francis Memorial Hospital logo
• Department Name
• Name of form (block left)
43
Upper right hand corner (header):
• Open space for patient identification - allow enough space for patient label (1”
height x 4” width)
Lower left hand corner (footer):
• Form number as assigned by the forms vendor (e.g. xxxx-xxx)

• Effective date of form
• Revision date of form (if revised)
Lower right hand corner (footer):
• Page designation (e.g. Page 1 of 2)
Header and footer information as listed above must be repeated on all pages and
both sides of multi-page forms.
Patient Identification - Every form to be maintained as a permanent part of the

patient’s medical record must contain at least the patient’s name, medical record number
and account/encounter number on every page, front and back. It is optimal to utilize the
patient identification label as provided to each care area for this purpose.
Signature Lines – All forms should contain a signature line for the care provider
and should also allow space for a date and time that corresponds with that signature.
Forms intended for patient’s to sign should also include a space for signature and date.
Paper size – when possible please use standard 8½ x 11” paper. Forms that fold open and
are greater than 8½ x 11” must have a page break within the fold of the document to
allow for splitting the pages without compromising the information within it (when
possible perforation is recommended).
Paper Stock – Forms to be used in the patient’s medical record must be printed on
paper stock that will withstand extensive handling. The optimal paper stock weight
should be 20 lb. This includes stock for standard one-part forms as well as multi-part
form sets. Onionskin, parchment and other lighter weight paper are not suitable for
medical record documents and will not be allowed.
Ink – Ink color for printed forms must be black. Red ink may be allowed as outline to textual
boxes if needed as allowable through the forms vendor.
Font Size - Recommended font is Arial or Times New Roman. Recommended font size
should be 10 or 12 point but no less than 7 point.
Multi-Part Form Sets/Routing – For forms with multiple copies (NCR) be sure to include
the copy designations (White – chart, Yellow – Pharmacy, etc.). It is recommended that the
44
original copy is retained as the medical record version. The maximum number of pages in a
multi-part form set is three copies.
Mounted Information – Please allow ample blank space on the form for any information
that is manually mounted (e.g. rhythm strips, etc.). Shingled forms should not be used for this
purpose.
Form users must make sure to tape down all margins of the strips that are
adhered to any form. Mounted information must not obstruct any handwritten
information on the form.
Writing Tools – Only black or blue ink is approved for handwriting in the medical record.
Colored pen ink is often lost to photocopying and/or electronic scanning. Thick felt tip pens
and markers should be avoided as it will bleed through forms and potentially obliterate notes
written on the back of the page or pages beneath. Pencils and other erasable writing tools
may never be used on forms to be maintained within the permanent medical record. Avoid
the use of highlighters as this may result in “black-out” of the highlighted areas.
Form Vendors Responsibility:
1. Forms Vendor will communicate directly with the Form Owner/Author to clarify any
information and if necessary offer assistance in further preparing the form with the
exception of making changes.
2. Forms Vendor will assign form numbers to new forms.
3. Forms Vendor will produce a "Proof" of the form and return it to the Form
Owner/Author and the Forms Chairperson for correction/approval.
4. Forms Vendor will work in conjunction with the HIM Department/Forms Committee to
produce forms as requested.
45
Merging Medical Record Numbers
POLICY: Medical records are merged when there are two or more medical record numbers
issued to the same patient. It is imperative that the merge not take place until it has validated that
the record numbers belong to the same patient. Since the merge results in a combined clinical
record, it is almost impossible to undo a merge. Merges can cross facilities, or be within a
facility.
PURPOSE: To ensure that the merging of medical record numbers takes place on appropriate
grounds and to avoid error in merging medical record numbers.
PROCEDURE:
Use the following criteria:
Cross facilities: always merge 01xxxxxx to 02xxxxxx

Within facility: always merge to the lowest MRN
New/Old MRN: always merge 10xxxxxx to either 02xxxxxx or 01xxxxxx which ever is
appropriate to the facility
o Log into LASTWORD. Check the name and/ or MRNs, check for demographic
information not matching. Print or note the differences. For example: If cross facility –
make sure the information from 01xxxxxx is noted, so you can add this to the correct
02xxxxxx patient record. AlsQ review CLIN for any clinical information that needs to be
added to the correct MRN. All other clinical data will be emerged electronically.
o Make note of both the incorrect and correct MRNs.
o Note: if patient cannot merge immediately without directive from manager of
HIM
Select the number you will be merging to (the correct number) and activate the patient.
Use the command: MRNMRG. Complete each screen, ensuring that you have entered the
numbers need accurately. On the last screen Pending Merge Request, in the Action
column use the B (batch mode) unless there is an immediate need for a merge. 8 will
become H
o Now with the correct MRN us the command FINC. On the first screen enter the incorrect
MRN in the alternative number field and click OK or press ENTER. Then return to
commend screen. This will add the alternative number to all Med. Rec. chart requests and
to the radiology requisitions to assist in finding the correct patient. The alternative
number will now be displayed on the patient name activation screen.
o The batch merges will be processed nightly. This will send an electronic message to the
Lab system – Sunquest and merges the records. An error report prints from Sunquest if
there are problems with the merge in the lab system.
o A report prints nightly of all merges completed, and can be printed by request from
LASTWORD using the command MRGREP.
46
Notification of Incomplete/ Delinquent Records
POLICY:
The records of discharged patients must be completed within two weeks according to the Saint
Francis Memorial Hospital Medical Staff Rules and Regulations.
Health Information Management services will notify physicians on the status of their incomplete
and/ or delinquent records on a weekly basis with a letter of a telephone call.
Every Tuesday morning of the week, HIM Services will prepare and send a suspension notice
and a list of their incomplete and delinquent records for those physicians who will have their
admitting privileges suspended for failure to complete their records in accordance with the
medical staff Rules and Regulations.
PURPOSE: To provide a guideline for the suspension of medical doctors due to their
delinquent and incomplete documents.
PROCEDURE:
Physicians Notification of incomplete of delinquent records

1. print a letter for each physician with incomplete and/ or delinquent records on
Tuesday morning
a. Click on MR Completion/ MR reports
b. Scroll and click on MRCREP—Completion Report
in MRC Command (9330)
c. Enter report number 21: Incomplete records by
responsible physician
d. Hold right click of mouse in printer location
e. Move cursor to S1. Francis (+ )- Printers in Printer
(16)
f. Double left click on the mouse
g. Double left click on the printer (+)- compressed
printer
h. Scroll and select printer
i. CHIM015-MedRec5 Incomplete Record Disk
Note: If any of the physicians that have a printed letter have come into the department to
complete the incomplete and/ or delinquent records during the time that you were processing the
letter, destroy the letter.
2. Destroy letter for physicians who routinely (weekly basis) complete their
records and those who are ill or are on vacation
3. Sort the letters into four (4) batches
a. 900 Hyde St.
b. 909 Hyde St.
c. 1199 Bush St.
47
d. Others
i. Alphabetize by physician
ii. Retrieve St. Francis logo window envelopes
iii. Bring to mail room for processing by noon. HIM Department
supplies window envelopes to Mail Room
4. Place the batch of letters for 900 Hyde, 909 Hyde and 1199 Bush in the
outgoing mail tray by Noon for delivery
Preparation of the suspension list/ letters
1. Print a list of physicians who have not as yet completed their delinquent
records on Friday.
a. Click on the MR Completion/ MR Reports
b. Scroll and click on MRCREP—Completion Reports in MRC
Command 9330
c. Enter report number 6: Provider’s Records Incomplete 14 days
d. Hold right click of mouse in the printer location
e. Move cursor to St. Francis (+)- Printers in Printer (16)
f. Double left click on the mouse
g. Scroll and select printer
h. .CHIM015MedRec Incomplete Dsk
2. Write the telephone number for each of the physicians on the list
a. Retrieve from the Medical Staff Roster or
b. Retrieve from LASTWORD in MD INFO
i. Click on MD INFO in the Health Information command screen
ii. Enter the physician name in the user # or name field of the
User Retrieval screen
iii. Hit F1
iv. Enter physician name in Lost Others: Type new # or last name
letter(s)
1. + send the Help with User Lookup screen
3. Call those physicians who have not been in complete the delinquent records
that suspension is imminent on Friday. Failure to do so will result in automatic
suspension for those delinquent records on Tuesday at 2:00pm
4. Write on the list
i. Date called
ii. Leave message with
iii. Deadline for completion to avoid suspension
5. Write on the list; whether a physician is ill, on vacation, or out of town, in

such cases, the physicians are permitted extra time to complete their records.
6. Update the list for those physicians who have completed their record before
the deadline
48
7. On Monday morning, review the list for those physicians who have not
completed the delinquent records, have not been allowed extra time to
complete the records and/or have other circumstances
a. Pull those records to verify that the records are indeed delinquent and
not completed
b. Note that the physician is ill, on vacation, or out of town
c. Unavailability of records for completion by the physician
d. Inadvertently missed items for completion
e. Make a note on the list
8. Print the suspension list (see attached) on Monday at 2:00pm

i. Click on MR Completion/ MR report
ii. Scroll and click on MRCREP- Completion Reports in MRC
Command (9330)
iii. Enter report number 2: MD’s on suspension, sorted by MD’s
name (B)
iv. Hold right click of mouse in print location
v. Mover cursor to St. Francis (+)- Printers in Printer (16)
vi. Double left click on the mouse
vii. Scroll and select printer
a. Send by mail to physician
b. Make an distribute copies accordingly
Medical Staff Office, Chief of Staff
Come and Go Unit: Admitting*, Surgery
Surgery scheduling, Doctor’s Lounge: Post up
on bulletin board
• Note: Print automatically upon the designated printer
c. File the list in the suspension binder with the list of

incomplete records over 14 days
i. report annually and/ or semiannually the
number of days spent suspended on two
years time period for the physician to the
Medical Staff Office update the
suspension list in LASTWORD on
Monday at 2:00pm
1. add new suspended physician(s)
to the list
a. click on MR completion
b. scroll and click on
MRCSDS- Add, update a
suspension
c. enter the physician’s
name
49
d. hit F1 to access physician
listing
e. scroll and select user
f. click Ok
g. enter item #
h. enter the physician name
in provider
i. hit F1
j. enter the reason code
k. enter the suspension date
l. click Ok
m. click on command screen
9. Remove the physician from suspension, when the physician has completed the
delinquent records
a. Draw a line across the physician name on the list
b. Not the date next the physician name on the list
c. Notify admitting (ext. 6200) and surgery (ext. 6522) by telephone
i. Click on MR completion
ii. Scroll and click on MRCSUP- Add, update, delete a
suspension
iii. Enter the physician’s name
iv. Hit PI to access physician listing
v. Scroll and select user
vi. Click Ok to hit enter
vii. Click On item # box for Delete and existing suspension
viii. Enter item number
ix. Hit enter
x. Enter clear date—mmddyyyy
xi. Enter clear code—CL
xii. Hit enter or click Ok
xiii. Click on command screen
Note: Article VII. Corrective Action under section 3 (d). Automatic Suspension or Limitation in
the Medical staff Bylaws states “Medical staff member are required to complete medical records
within fourteen (14) days of a patient’s discharge. Failure to timely complete a medical record
shall result in automatic suspension after notice is given. Such suspension shall apply to the
medical staff member’s right to admit, treat, or provide services to new patients in the hospital,
but shall not affect the right to continue to care for a patient the medical staff member has
already admitted or is treating. The suspension shall continue until the medical records are
completed”
50
Quantitative Analysis
POLICY: It is the policy of the Health Information Management Department to perform
quantitative analysis of medical records in order to expedite physician completion.
PROCEDURE:
1. Retrieve the oldest group of inpatient unanalyzed charts from the Day Group Shelf on the
East Wall of the HIM Dept
2. Write the date and time of discharge on the face sheet
3. Analyze using the Inpatient Analysis criteria below
4. Flag each deficiency with a colored flag using a different color for each physician
5. Enter deficiencies into the deficiency system
6. Print deficiency record and file on the left side of the chart
7. Place add additional colored flags on the deficiency record that corresponds to each of the
“dictation/ signature” deficiencies cited for each physician. Match the colors used in step
#4.
8. When analysis is complete, initial the HIM Tracking Form (found on the lefts side of the
chart).
9. File the chart as follows:
a. Coded charts: File on the incomplete wall in terminal digit order or in a
physicians’ stack
b. Un-coded charts: File on the day-group shelf by discharge date in TD order.
I. Analysis Criteria: Inpatient/ SNF/ Rehab Records
Document Quantitative Documentation requirements

Discharge summary  Must be present for all inpatient charts
with a LOS of 48 hours or more, deaths
and complicated stays
 Must be signed by a dictating physician
Discharge summaries may be dictated or and
written
Diagnosis Summary Sheet Must be completed for all uncomplicated stay
inpatient charts with a LOS of under 48 hours
unless the MD has dictated a Discharge
Summary
History & Physical examination  Must be completed within 24 hours of
admission unless
A. The patient was readmitted within 7
days for the same or a related
condition. In this case the H&P
from the prior admission coupled
with an Interval Note (within 24
hours) meet the requirements of an
51
H&P.
B. An H&P completed within days of
admission meets the requirements if
the accompanied by an Interval
Note (within 24 hours)
 Must be signed
Consultation  Review only for signature (note: do not
review order for consult requests)
Operative Report  Must be written or dictated immediately
following surgery
 Must be signed by a surgeon
Pathology report  Must be present if a specimen was taken
to Pathology
 Must be signed
Orders/ Verbal Orders  Flag for signature, date and time
Anesthesia Record  Signed by anesthesiologist
Anesthesia Flow sheet  Signed by surgeon
Queries  Flag for signature and date
Progress Notes  Flag for signature and date
II. Inpatient Psychiatric Records
East Wall of the HIM dept
6. Print deficiency record and file on the left side of chart
“dictation/signature” deficiencies cited for each physician. Match the colors used in step
#4
8. When analysis is complete, initial the HIM Tracking form (found on the left side of each
chart)
9. File the chart as follows
a. Coded Charts: File on the incomplete wall in terminal digit order or in a
physician’s stack
Analysis Criteria: Inpatient Psychiatric Records
Psychiatric Admission Note  Must be present
 Must be signed by a dictating physician
History & Physical Examination  Must be completed within 24 hours of
admission unless
a. The patient was readmitted within 7 days
52
for the same or a related condition. In this
case the H&P from the prior admission
coupled with an interval note (within 24
hours) meet the requirements of an H&P
b. An H&P completed within 7 days of
admission meets the requirements if
accompanied by an interval note (within
24 hours).
 Must be signed
Diagnosis summary Must be completed for all uncomplicated stay
inpatient charts with a LOS of under 48 hours
unless the MD has dictated a discharge
summary
Multidisciplinary Treatment Plan  Must be present
 If treatment plan is signed by physician
signature also.
Orders/ Verbal Orders  Flag for signature, date, and time
Anesthesia record  Signed by anesthesiologist
Riese Affidavit  Signed by physician
Queries  Flag for signature and date
Progress notes  Flag for signature and date
Discharge summary  Must be present for all inpatient charts
with a LOS of 48 hours or more,
deaths, and complicated stays
 Must be signed by dictating physician
Discharge summaries may be dictated or
handwritten
III. Come and Go Unit
East Wall of the HIM dept
“dictation/signature” deficiencies cited for each physician. Match the colors used in step
#4
17. When analysis is complete, initial the HIM Tracking form (found on the left side of each
chart)
18. File the chart as follows
a. Coded : File on the incomplete wall in terminal digit order or in a physician’s
stack
53
Analysis Criteria: Come & Go

Document Quantitative Documentation Requirements
History & Physical Examination  Must be completed prior to surgery. An
H&P completed within 30 days prior to
admission may be used if accompanied
by an Interval Note.
 Must be signed
Operative Note  Must be written or dictated immediately
Procedure Note following surgery
 Must be signed by surgeon
Pathology Report  Must be present if a specimen was taken
to Pathology
 Must be signed
Anesthesia Flow Sheet  Signed by surgeon
Anesthesia Record  Signed by anesthesiologist
Progress Notes  Flag for signature and date
IV Outpatient Behavioral Health
1. Retrieve outpatient behavioral health charts from the OP Behavioral Health box located
on the Day Group shelf on the east wall of the HIM Dept
2. Print all face sheets for patient with length of stay more than one month ( Note: there will
be a separate face sheet and account number for each month of the patient’s treatment
period)
3. Write the date and time of discharge on the most recent face sheet (Note: Analysis will be
recorded using the most recently assigned account number)
4. Analyze using the criteria below
dictation/signature deficiencies cited for each physician. Match the colors used in step #4
9. When analysis is complete, initial the HIM tracking form
10. File the chart on the incomplete wall in terminal digit order or in a physician’s stack
Analysis Criteria: Outpatient Behavioral Health
Document Quantitative Documentation Requirements

Psychiatric Admission Note  Must be present
 Must be signed by dictating psychiatrist
History & Physical Examination  Must be completed within 24 hours of
54
admission unless
A. The patient was readmitted within 7
days for the same or a related
condition. In this case the H&P
from the prior admission coupled
with an interval note meet the
requirements of an H&P.
B. An H&P completed within 7 days
of admission meets requirements if
accompanied by an Interval Note
 Must be signed
 If H&P and/or Interval Note are
missing, assign the deficiency to the
Program Medical Director
Consultation  Review only for signature (Note: do not
review orders for consult requests)
Discharge Summary  Must be present
 Must be signed by dictating physician
Discharge summaries may be dictated or
handwritten
Multidisciplinary Treatment Plan  Must be present
 Must be signed by MD
55
Re-Analysis of Patient Records for Completion
Health information Management
POLICY: Delinquent and/or Incomplete Records that physician(s) have come in to complete
(dictate/sign) must be checked for completion according to the Medical Staff Bylaws, JCHAO
Standards and Title 22 Rules and Regulations within 24 hours.
PURPOSE: To provide guidelines for the process of re-analysis of incomplete and delinquent
records to ensure the appropriate status of all physician’s medical records are accurate.
PROCEDURE:
1. Gather all incomplete and/or delinquent records that the physicians have come in to
complete
2. Check the records for completion (see chart analysis policy and procedure)
A. Update completed deficiencies as follows
i. Update in LASTWORD
MRC- Maintain a patient’s record deficiency
o Enter the MRN
o Click on MR completion
o Double click on MRC- Maintain a patient’s record deficiency
o Select and click on the appropriate encounter from the Medical
Record Completion History
o Enter date for all completed OR
o Enter status C/P for each deficiency C= Clear P=Pending OR
o Hit enter/ Ok
MRCC- Mass updates to responsible provider
o Double click on MRCC- Mass updates to responsible provider

o Enter physician number (#) in deficiencies for provider
o Enter status C/P C=Clear P=Pending
o Enter change all Y=Yes N=No (optional)
o Click on the boxes that correspond to the deficiency you want
to update for each record
o Hit enter or click Ok
MCPRV- Update one acct for one provider

o Double click on MRCPRV- Update one acct for one
provider
o Enter physician in responsible provider in update physician
deficiencies by account
o Enter account number
56
o Change due date by entering new date
o Enter Y= apply to all listed below
o Change status by entering new status Y=Yes N=No
o Enter Y- apply to all listed below
o Click on the deficiency
o Click Ok
3. Remove redi-tags
4. Dispose of the deficiency slip
5. Route the record for
i. Filing in the main file
ii. Coding/ abstracting
Note: Red initials on the face sheet= completed
B. If deficiencies remain on the patient record:

i. Update the deficiency slip in record
ii. Update in LASTWORD
iii. File the record into the incomplete record file
C. For emergency services reports in the emergency service physician folders, check
for completion
i. If complete, place in the emergency services reports filing basket
ii. If not complete, place in the emergency services physician folder
57
Reports for Signature/ Completion
POLICY: Reports shall be mailed or faxed for signature or completion when appropriate,
such as upon request by the physician(s) or infrequent visits to the hospital by the physician.
PURPOSE: To ensure that reports are delivered appropriately and effectively for completion
and signatures.
PROCEDURE:
1. Print the MD deficiency list.

2. Locate and pull the record(s)
3. For mailing:
a. Remove the original report and copy the report which needs signature/ completion
(e.g. discharge summary, history & physical, consultation, operative report, face
sheet/ attestation)
b. Flag the deficiency(ies) on the original and copied report with a redi-tag
c. Prepare and place a note to the physician to be completed within an appropriate
time frame
d. Prepare two envelopes
i. Mailing
ii. Self addressed/ return
e. place the original report, note to the physician and return envelope into the
mailing envelope; seal the mailing envelope; and place in the outgoing mail tray
(in-house delivery/ via US Postal Services)
f. file the copy of the report in place of the original report in the record
g. write signature/completion by the physician on MMDDYYYY (date)
h. file the record back into the incomplete record file
4. For faxing:
a. Complete a cover sheet
b. Remove the original report
c. Fax the cover sheet and report
d. File the original report and cover sheet in the record
e. File the record back into the incomplete record file
5. After the report is signed/ completed and returned, pull the medical record, insert the
completed original report, rip out the copied report, final check the record for completion
(yes= remove the deficiency slip from the record and update in LASTWORD; (no=
repeat steps 1-10)
58
Running Reports
POLICY: Reports shall be generated from LASTWORD and Clinitrak on daily, weekly,
monthly, annually and/or as needed basis.
PURPOSE: To provide guidelines for the generation of reports, and to ensure that reports are
generated on a regular, constant schedule.
PROCEDURE:
LASTWORD
1. Click on MR Reports
2. Double click on report
o MRCREP- Completion Reports
o MRADTREP-ADT and Management Reports
o ADTREP-ADT Reports
3. Enter report number
4. Enter start date
5. Right click and hold on the mouse and printer location
6. Double left click on St. Francis (+)- Printer
7. Double left click on Printers (+)- Compressed printers
8. Scroll and select printers
o CHIM011- MedRec1 Coding Area
o CHIM012- MedRec2 Data Q Coor
o CHIM015- MedRec5Incomplete Record
o CHIM018- Med Rec8ROI
9. Double left click on select printer

10. Click OK
CLINITRAK
1. Click on Reports
2. Click on Administrative Reports
3. Click on Report List Tab
4. Choose
o Standard- template
o Custom- template
5. Select and click on report category

6. Select and click on report name
7. Click on range tab
8. Enter date range
o Discharge date ___to___
59
9. Click on Edit list
o Patient type
o Procedure list
o Diagnosis list
o DRG list
o Discharge department
o Discharge service
i. Scroll and select
ii. Highlight the selected code
iii. Click on the arrows
>= add one code to the list
<= delete one code from the list
 >= add all at once to the list
 «= delete all at once from the list
10. Enter ICD-9-CM/ CPT code range

o Diagnosis code __to__
o Procedure code __to__
11. Enter Y/N

o Principal only?
o Totals only?
12. Click on sort group tab

o Click on down arrow key to pull up table
o Scroll and select from report sort order table
o Click okay
13. Click on destination icon

o Send report to display
o Send report to printer
o Send report to a file
14. Click on print report icon to print a report

15. Click on done icon to cancel a report
16. Click on X to delete a report
17. Click on save report to a file
60
Unit Patient Record
POLICY: Patient records at St Francis Memorial Hospital are maintained in their original
paper form in a unit record. It combines the following records:
 Inpatient
 Come and Go Unit
 Ambulatory Treatment Center
 Sports Medicine
 Emergency Room
 Spine Clinic
 Outpatient Chemotherapy
 Plastic Surgery and Outpatient Burn Clinic
 Wound Center
 Franciscan Treatment Room
These records are physically stored in one or more folders (depending on amount of material) in
the centralized filing areas in the Health Information Management Services of the hospital or in
the off-site storage in terminal digit order by year.
61
Acute Medical/Surgical Care Chart Order
 Diagnosis Summary Sheet/ Physician Attestation Form/ Coding Summary Form
 Demographic face Sheet
 Patient Self- Determination
 ACV Doc Compliance
 Death Certificate
 Autopsy Report
 Discharge/ Death? Transfer Summary
 Emergency Services Report
 Consent for Treatment Emergency Services
 Triage/ Emergency Service Flow Sheet
 History and Physical
o Pre-operative history and physical
 Admit Note
 Consultations
 Progress Notes
 Chaplaincy Service Notes
 Cardiac Arrest Records
 Informed Consent
 Authorization for and Consent to Surgery or Special Diagnostic/ Therapeutic Procedures
 Pre-Operative Check List
 Operating Room Nurse’s Record
 Anesthesia Record
 Recovery Room Record
 Operative Report
 Pathology Report
 Laboratory Summary Report ( Final= Brown Strips replace interim [blue strips] Lab is
brown striped)
 Other Laboratory Reports
 Authorization for Blood Transfusion
 Blood Transfusion Report
 Cytology Report
 Radiology Report
 Nuclear Medicine Reports
 Electrocardiogram
 24 Hour Ambulatory Cardio graphic Report
 Monitoring Reports
 Echocardiogram
 Treadmill
 Electroencephalogram Report
 Electromyogram Report
 Electronystagnogram
62
 Pulmonary Function reports
 Audiological Evaluation
 Physician’s orders
o Anesthesia
o Pre Operative
o Post operative
 Physician’s Discharge Orders
 Interdisciplinary Patient/ Resident/ Family Education Summary
 Occupational Evaluation
 Therapy Progress Notes
 Physical Therapy Progress Notes
 Physical Therapy Evaluation
 Respiratory Care Services Therapy Record
 Oxygen or Aerosol Therapy Record
 Speech Therapy
o Bedside Dysphagia Evaluation
 Therapy Progress Note ( Activates Therapy Limited Assessment)
 Art & Play Therapy
 Multidisciplinary Patient/ Family Education Tool
 Graphic Sheet
 24 Hour Fluid Balance Record
 Medication Administration Record (by last date on page)
 PCA Flow sheet
 Anticoagulation Therapy Record
 Bladder Training Record Sheet
 Blood Pressure Records
 Bowel Program Record Sheet
 Burn Unit Flow Sheet
 Diabetes Record
 Hemodialysis Record
 IV Therapy Service
 Neurological Observation
 Restraints
 Total Parental Therapy Record
 Interdisciplinary Case Management Assessment
 Initial Nursing Assessment Data Base
 Care Plan Supplement
 Patient Admission Screening and Assessment
 Multidisciplinary Plan of Care and Flow Sheet
 Multidisciplinary Clinical Path
 24 Hour Care Record
 24 Care Flow Sheet
63
 Conditions of Admission
 Non- Covered Notice
 Interfacility Transfer
 Ambulance Company Form
 Personal Effect Record
 Other Consent Form
 Transfer to Another Hospital
64
Acute Medical/Surgical Care Chart Order (Block Format)
Category Form Comment

Diagnosis Summary Sheet/
Physician Attestation Form/
Coding Summary Form
Demographic face Sheet
Patient Self- Determination

ACV Doc Compliance
Death Certificate
Autopsy Report
Discharge/ Death? Transfer

Summary
Emergency Services Report
Consent for Treatment

Emergency Services
Triage/ Emergency Service

Flow Sheet
History and Physical

Pre-operative history and
physical
Admit Note
Consultations
Progress Notes
Chaplaincy Service Notes
Cardiac Arrest Records
Informed Consent
Authorization for and Consent

to Surgery or Special
Diagnostic/ Therapeutic
65
Procedures
Pre-Operative Check List
Operating Room Nurse’s

Record
Anesthesia Record
Recovery Room Record
Operative Report
Pathology Report
Laboratory Summary Report

( Final= Brown Strips replace
interim [blue strips] Lab is
brown striped)
Other Laboratory Reports
Authorization for Blood

Transfusion
Blood Transfusion Report
Cytology Report
Radiology Report
Nuclear Medicine Reports
Electrocardiogram
24 Hour Ambulatory Cardio

graphic Report
Monitoring Reports
Echocardiogram
Treadmill
Electroencephalogram Report
Electromyogram Report
66
Electronystagnogram
Pulmonary Function reports
Audiological Evaluation
Physician’s orders
-Anesthesia
-Pre Operative
-Post operative
Physician’s Discharge Orders
Interdisciplinary Patient/
Resident/ Family Education
Summary
Occupational Evaluation
Therapy Progress Notes
Physical Therapy Progress

Notes
Physical Therapy Evaluation
Therapy Progress Notes
Respiratory Care Services

Therapy Record
Oxygen or Aerosol Therapy

Record
Speech Therapy
-Bedside Dysphasia Evaluation
Therapy Progress Note

( Activates Therapy Limited
Assessment)
Art & Play Therapy
Multidisciplinary Patient/
Family Education Tool
67
Graphic Sheet
24 Hour Fluid Balance Record
Medication Administration
Record (by last date on page)
PCA Flow sheet
Anticoagulation Therapy
Record
Bladder Training Record Sheet
Blood Pressure Records
Bowel Program Record Sheet
Burn Unit Flow Sheet
Diabetes Record
Hemodialysis Record
IV Therapy Service
Neurological Observation
Restraints
Total Parental Therapy Record
Interdisciplinary Case
Management Assessment
Initial Nursing Assessment Data

Base
Care Plan Supplement
Patient Admission Screening

and Assessment
Multidisciplinary Plan of Care

and Flow Sheet
68
Multidisciplinary Clinical Path
24 Hour Care Record
24 Hour Care Flow Sheet

Conditions of Admission
Non- Covered Notice
Interfacility Transfer
Ambulance Company Form
Personal Effect Record
Other Consent Form
Transfer to Another Hospital
69
Acute Rehabilitation (Rehab) Center Chart Order
 Diagnosis Summary Sheet/ Physician Attestation Form/ Coding summary Form
 Demographic Face sheet
 Advance Directives
 Discharge Summary
 Emergency Services Registration
 Consent for Treatment
 Triage/ Emergency Service Flow sheet
 Consultations
 Rehab Team Conference
 Progress Notes
 Chaplaincy Services Notes
 Authorization for and Consent to Surgery or Special Diagnostic/ Therapeutic
Procedures
 Procedure Report
 Laboratory
 Cytology
 Authorization for Blood Transfusion and Informed Consent to Surgery and Special
Diagnostic/ Therapeutic Procedures
 Transfusion Record
 Radiology
 Echocardiogram
 Rehab Admission Orders
 Physician’s Orders
 Discharge Orders
 Interdisciplinary Patient/ Resident/ Family education Summary
 Acute/ SNF Occupational Therapy Evaluation
 Therapy progress notes
 Respiratory Care Ventilator Flow Chart
 Respiratory Care Chart
 Oxygen or Aerosol Therapy Record
 Oximetery Results Report
 Rehab Treatment Plan

 Psychosocial/ Recreation Contact Record
 Multidisciplinary Care Plan\
 Multidisciplinary Patient/ Family Education tool
70
 Patient and Family Teaching Record
 Graphic Sheet
 24 Hour Fluid Balance Record
 Medication Administration Record
 Bladder Training Record Sheet
 Bowel Program Record Sheet
 Diabetic Chart
 IV Therapy
 Interdisciplinary Case Management Assessment
 Occupational Therapy Assessment/ Discharge Status
 Treatment Summary
 Physical Therapy Assessment/ Discharge Status
 Social and Family Assessment/ Discharge Status
 ARU Pre-admission Evaluation
 Nursing Assessment
 Supplement Care Plan
 Nursing Care Plan/ Progress Report
 24 Hour Care Plan
 Condition of Admission
 Interfacility Transfer
 Patient and Family Agreement
 Patient’s Rights and Responsibilities
 Patient/ family Orientation Checklist
 Ambulance Record
 Personal Effects Record
 Daily Report Form/ Chargemaster
71
Ambulatory Treatment Center Chart Order
 Diagnosis Summary Sheet/ Physician Attestation Form/ Coding Summary Form

 Treatment Center Patient Summary
 History & Physical/ Short history and Physical for Immediate Pre-Anesthetic Assessment
 Pre-procedural Assessment
 Progress Notes
 Photograph
 Endoscopy Discharge Instructions
 Authorization for and Consent to Surgery
 Pre-Anesthesia Evaluation Assessment for Invasive Procedures
 Conscious Sedation Flow Sheet
 Anesthesia by Non-Anesthesiologists Flow Sheet
 Pathology
 Come and Go/ GI Services Multidisciplinary Plan of Care and Flow Sheet
 CGU Flow Sheet
72
Come and Go Unit (CGU) Chart Order
 Diagnosis Summary Sheet/ Physician Attestation Form/ Coding Summary form

 Progress Notes
 Authorization for an Consent to Surgery
 Pre-operative Check List
 Operating Room Nurse’s Record and Pre-operative Screen
 Recovery Room Record
 Pathology Report
 Laboratory Report
o Pre-operative
o Post-operative
 Physician’s Discharge Orders
 Interdisciplinary Patient/ resident/ Family Education Summary
 CGU Flow Sheet
 Coding Summary Form
 Diagnosis Summary Sheet
 Physician Attestation Form
 Advanced Directives
 Triage
 Additional Doctor’s Notes
Dictation
Short Form H&P
 Progress Notes
o Pre Op
73
o Post Op Notes
o Total joint Center Progress Notes
o Orthopedic Interdisciplinary Round
 YAG Note: orders go before Adult Ambulatory Screenings

 Orthopedic Note; Neurosurgery Interdisciplinary Rounds Summary
 Spiritual Care Assessment
 Authorization for and Consent to Surgery
 Pre-anesthesia Evaluation and Assessment
 Pre-operative checklist
 Operating Room Nurse’s Record and Pre-operative Screen
 Anesthesia by non-anesthesiologist
o Post anesthesia care unit record
 Treatment center patient summary

 Recovery room record
 Procedure report- operative report
 Pathology report
 Treatment center endoscopy discharge instructions
 Lab report
 Transfusion
o Note; informed consent from above, IF it’s about blood. Hematology
 EKG (electrocardiogram)
 Surgery Scheduling, Authorization & Orders
 Physicians Order
o Pre admission Testing
o Pre Operative
o Clinical Lab request Form
o Anesthesia Orders
o Post- Operative
o Regular Order Sheets
o Instructions
 Physicians Discharge Orders
 Discharge Patient/ Resident/ Family Education Summary
 Oxygen or Aerosol Therapy record
 Physical Therapy Section
 Multidisciplinary Plan of Care
 Dear Come and Go Surgery Patient
 24 Hour Fluid Balance
74
 Care Plan Supplement (folder/nursing)
 Graphic Sheet
 Come& Go Services flow sheet
 Initial Nursing Assessment Database (adult)
 Adult Patient Admission Screening and Assessment
 24 hour Care Record
 Adult Patient Assessment and Psychiatry
 Personal Effects
 Confirmation of Reservation for Surgery
 Joint Notice of Privacy Practices
 Insurance Card Photocopies
75
Emergency Services Chart Order
 Emergency Service Evaluation
 Triage/ Emergency Services Flow Sheet
 Laboratory
 Radiology
 Doctor’s First Report
 Ambulance Company form
 Other Consent Form
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Psychiatric Chart Order
Left Side of Chart Folder
 Advance Directive
 Correspondence
Right Side of Chart Folder

 Diagnosis Summary Sheet/ Coding Summary Form
 Discharge Summary/ Transfer Summary
 Triage/ Emergency Services Flow Sheet
 Psychiatric Admission Note
 History & Physical Examination
 Consultation
 Interdisciplinary Psychosocial Assessment Tool
 Progress Notes
 Department of Psychiatry Multidisciplinary Progress Note
 Laboratory Summary Report
 Other Lab Reports
 Blood Transfusion report
 Electroencephalogram report
 Discharge Patient’s Orders
 Western Psychiatric Center Admission Orders
 Behavioral Health Services Admission Orders
 Department of Psychiatry- Interdisciplinary Patient/ Family Education
 Multidisciplinary Patient/ Family Education Summary
 Rehabilitation Therapy Assessment
 Interdisciplinary Treatment Plan
 Behavioral Health Interdisciplinary Plan of Care
 Restraints/ Seclusion Reduction Data
 Close Watch- 15 Minute Observation record
 Department of psychiatry activity record/ graphic sheet
 Medication Administration record
 Interdisciplinary Assessment Screening and Plan of Care
 Involuntary Patient Advisement
 Application for 72 hours detention
 Notification of Patient’s Admission/ Notice to Patient
 Request for Voluntary Admission and Authorization for Treatment
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 Certification Review Hearing
 Notice of Certification
 Section 5331 of the California Mental Health Services Act States That…
 Behavioral Health Services Patient Advisements
 Medication Consent form
 Mental Health Facilities Report of Firearms Prohibition
 Joint Notice of Privacy Practices for Health Information (NPP) Acknowledgement Form
 Patient notification of firearms prohibition & right to hearing
 Patient Property record
 Discharge Checklist
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Psychiatric Assessment
 Diagnosis Summary Sheet
 Multidisciplinary Progress Notes
 Laboratory Report
 Physician’s orders
 Medication
 Behavioral health Assessment Center
o Intake and Assessment Form/ Tool
o Initial Risk Assessment Part A
o Triage Record Part B

 Medication Consent Form
 Release of Information to Significant Other
 Other Consents
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Skilled Nursing Facility (SNF) Chart Order
 Diagnosis Summary Sheet/ Physician Attestation Form. Coding Summary Form
 Demographic Face Sheet
 Skilled Nursing Facility Physician Admission Progress notes
 Progress Notes
 Chaplaincy Service Notes
 Laboratory
 Radiology
 Physician Admission Orders
 Patient Discharge Orders
 Acute/ SNF Occupational Therapy Evaluation
 Therapy progress notes
 Physical Therapy Evaluation
 Respiratory Therapy Evaluation
 Respiratory Therapy Daily Services
 Oxygen or Aerosol Therapy record
 Multidisciplinary Care Plan
 Multidisciplinary Patient/ Family education Tool
 Graphic Sheet
 IV Therapy Initial Assessment
 Initial Nutrition Assessment
 Minimum Data Set (MDS) Sheet
 Admission Screening
 Supplemental care Plan
 24 Hour care plan
 Conditions of admission
 Interfacility transfer
 24 Hour Care Record
 ADL Record
 Minimum Data set
 RAP Sheet
 Care Plan
 Lab
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 Treadmill
 EKG
 Resident Admission Agreement
 Patient Rights--- Skilled Nursing Facilities
 Ambulance company Form
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Transplant (Organ) Donor Chart Order
 Attestation/ Coding Summary Form/ Diagnosis Summary Sheet
 Death Certificate
 Progress Notes
 Consent for Transplant Donor
 Authorization for and Consent for Surgery or Special Diagnostic/ Therapeutic
Procedures
 Physician’s Order
 Laboratory
 Radiology
 Electroencephalogram
 Physician’s Order
 Initial Nursing Assessment data base
 24 Care Record
 Personal Effects record
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After Hours Access to Medical records Stored Outside of the Health
Information Management Services Department
POLICY: It is the policy of Saint Francis Memorial Hospital to ensure that medical records
of patients are available as needed 24 hours a day for patient care.
PURPOSE: To ensure that medical records are available to the patients of Saint Francis
Memorial Hospital at all times and to provide a guideline on how to access these files after
hours.
PROCEDURE:
RESPONSIBILITY TASK
Clinical Nursing When a physician determines that an existing clinic medical
Units record is needed for patient care purposes after the regular
business hours of hospital clinics, hospital security will be
contacted to retrieve the medical record.
Security Staff Retrieve the requested clinic medical record from the clinic as
follows:
Hospital-Based Clinics: Retrieve the record following the
protocol identified below for each clinic.
Health Center @ SBC Park: Contact the clinic representative
identified in the protocol identified below.
Walnut Creek Sports Medicine Clinics: Contact the clinic
representative identified in the protocol identified below for
retrieval.
Corte Madera Sports Medicine Clinics: Contact the clinic
representative identified in the protocol identified below for
retrieval.
Off Site Clinics

Heath Center @ Upon receipt of request from hospital Security Personnel, retrieve
SBC Park the medical record from the clinic and fax relevant portions of the
Representative record to the hospital within one hour of the request. Contact the
Clinic Representative as follows:
Director, Rehab Services.
Walnut Creek Sports Upon receipt of request from Hospital Security Personnel, retrieve
Medicine Clinic the medical record from the clinic and fax relevant portions of the
record to the hospital within one hour of the request. Contact the
Clinic Representative as follows: Manager, Sports Medicine
Clinic
Corte Madera Sports Upon receipt of request from Hospital Security Personnel, retrieve
Medicine Clinic the medical record from the clinic and fax relevant portions of the
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record to the hospital within one hour of the request. Contact the
Clinic Representative as follows: Manager, Sports Medicine
Clinic
Hospital Security Hospital Based Clinics

Personnel
Sports Medicine: Hospital Security Personnel will retrieve
records from the clinic:
Location of Charts? Back Office area of 11th Floor Sports Med
Clinic.
Locked Filing Cabinet? No
Filing Sequence: TERMINAL DIGIT
Spine Center: Hospital Security Personnel will retrieve records

from the clinic:
Location of Charts: Room on the right of the conference room
Filing Sequence of Charts? ALPHA
Total Joint Center: Hospital Security Personnel will retrieve

Location of Charts: Room located to left of front desk
Wound Center: Hospital Security Personnel will retrieve

Location of Charts: Room 518
Burn Clinic: Hospital Security Personnel will retrieve records

from the clinic:
Location of Charts: Burn Unit – Med Room (Obtain key at
nursing station)
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OP Therapy Services (SFMH Location): Hospital Security
Personnel will retrieve records from the clinic:
Current Charts
Location of Charts: Hand Treatment Room – in cabinet
Locked Filing Cabinet? Not usually locked, but cabinet has lock
Filing Sequence of Charts? Alpha
Old Charts
Location of Charts: Gym (adjacent to the front office) in
cabinets
Filing Sequence of Charts? Filed by year of last treatment in Alpha order
OP Therapy Services (1199 Bush Street –Suite 140): Hospital

Security Personnel will retrieve records from the clinic:
Current Charts
Location of Charts: Reception Area – in cabinet
Old Charts
Location of Charts: Staff Room – accordion Folder
Filing Sequence of Charts? Filed by year of last treatment and Alpha
Franciscan Treatment Room: Hospital Security Personnel will

retrieve records from the clinic:
Location of Charts: Charts are located in the front reception area
and employee medical records are in locked cabinets in the back
hallway
Locked Filing Cabinet? Yes
Radiation Oncology Clinic: Hospital Security Personnel will

retrieve records from the clinic:
Location of Charts: Location of Charts: Storage rooms in back of
the reception area for patients that are no longer under treatment.
For current patients undergoing radiation therapy the chart will be
found next to the treatment machines.
Hyperbaric Clinic: Hospital Security Personnel will retrieve

Location of Charts: File cabinets in hallway of Hyperbaric and
exam room
Locked Filing Cabinet? Yes
Chemotherapy Infusion Clinic: Hospital Security Personnel
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will retrieve records from the clinic:
Location of Charts: Room 1033 – file cabinet
Melanoma Clinic: Hospital Security Personnel will retrieve

Location of Charts: 4th Floor Tub Room (across from
room 425)
OP Behavioral Health Day Program: Hospital Security

Personnel will retrieve records from the clinic:
Location of Charts: Nursing Station
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CONFIDENTIALITY AGREEMENT
I understand that during my tour (group or individual observation) of Saint Francis Memorial
Hospital (SFMH) I may be allowed access into patient care areas and/or areas that contain
protected health and/or confidential patient information. I understand that any information I may
see or hear is considered confidential information. Federal and State laws protect patient
privacy and confidentiality, any disclosure of protected health and/or confidential information is
prohibited. Protected health and/or Confidential information may not be shared with individuals
who are not part of the patient care team without the written permission of the patient. Protected
health information is any information about a person’s physical or mental health condition, the
healthcare provided (past, present or future) to the person or any payment for for that care that
includes but is not limited to the following: name, address, date of birth, telephone numbers,
email address, social security numbers, medical record number, account numbers or health plan
beneficiary numbers. Protected health information also includes descriptions of any
distinguishing markings or characteristics a patient may have including, but not limited to scars,
tattoos, birthmarks, moles, etc.
I further understand that during my tour of SFMH, no photographic or digital images may be
captured and/or retained by any device regardless of media in any patient care area or area
containing protected health information without the written authorization of the patient. The use
of cellular phones and camera phones by tour members in all patient care areas and areas
containing protected health information is also prohibited.
I also understand that non-compliance with any of the statements above will result in the
immediate termination of my tour at Saint Francis Memorial Hospital and may result in a report
of a privacy violation being filed with the Office of Civil Rights, Department of Justice, CHW,
and Saint Francis Memorial Hospital.
By signing below, I hereby acknowledge that I have read or been given the information in the
above agreement by a qualified interpreter. I also acknowledge that I understand all information
contained in the agreement. I further acknowledge that I will comply with all statements and
requirements of this agreement.
_____________________________________________ _____________________
Print Name Date
Signature
Name of CHW employee or medical staff responsible for this tour or individual observation
87
Authorization Requirements for Uses and Disclosure of PHI
POLICY: It is the policy of Catholic Healthcare West (CHW) to;
A. Require an Authorization for all Uses and Disclosures of Protected Health Information (PHI),
including marketing and employment determinations1, except2:
1. For a CHW Facility’s patient directory in accordance with the CHW Facility Patient
Directory, policy # 110.1.005;
2. For persons involved in the patient’s care and for notification purposes in accordance with
CHW Family and Friends, policy #110.1.013;
3. When permitted by HIPAA and required by law in accordance with CHW Disclosing
Protected Health Information as Required or Permitted by Law, policy # 110.1.012;
4. For access to PHI preparatory to Research and for access to PHI for Research on decedents
when accompanied with an approved Researcher’s
5. For access to PHI for Research with an approved Waiver of Authorization in accordance with
CHW Research – Use and Disclosure of PHI, policy #110.1.017;
6. For use with a Limited Data Set or for the use or De-identified Data in accordance with CHW
De-identified Health Information and Limited Data Set Use and Disclosures, policy
#110.1.016;
7. For Treatment, Payment, or Health Care Operations in accordance with CHW Use and
Disclosure of Protected Health Information for Treatment, Payment and Health Care
Operations, policy #110.1.018;
8. Additional state restrictions on the Use and Disclosure of PHI may apply to PHI for genetic
testing, communicable disease, mental health, HIV/AIDS, and substance abuse. Refer to state
specific procedures below and CHW applicable procedures for specific requirements if any; and
9. In other situations where CHW policy specifically permits a Use or Disclosure of PHI without
a written Authorization.
B. Require and Authorization for Psychotherapy Notes to carry out specified Treatment,
Payment or Healthcare Operations in accordance with CHW Use and Disclosure of Mental
Health and Substance Abuse, policy #110.1.026
C. The provision of treatment or eligibility for benefits to an individual may not be conditioned
on signing an Authorization except for:
1. Research related treatment
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2. Health care that is solely for the purpose of creating information for disclosure to a third party
D. An employee benefit health plan may condition enrollment in the plan or eligibility for plan
benefits prior to the individual’s enrollment in the plan, if:
1. The authorization sought is for the plan’s eligibility or enrollment determinations relating to
the individual or for its underwriting or risk rating determinations; and
The Authorization is not for a use or disclosure of Psychotherapy Notes.
E. All Authorizations must satisfy specific requirements as described in the following

procedures. Authorizations that fail to satisfy each of these requirements may not be valid and, as
such, no PHI may be Used or Disclosed in any manner based on such an invalid Authorization.
F. Use only applicable Model Authorization forms or other CPDSA approved templates when
seeking an Authorization. Model Authorization forms include:
1. General Authorization (attached hereto as Exhibit A);
2. Marketing Authorizations (see Marketing Communications, policy #110.1.021);
3. Psychotherapy Notes (see Use and Disclosure of Mental Health and Substance Abuse, policy
#110.1.026);
4. Fundraising (see Fund Development – Use and Disclosure of PHI, policy # 110.1.020); and
5. Research Authorizations (see Research – Use and Disclosure of PHI, policy # 110.1.017).
6. Outside Parties in the Procedure Room Authorization (attached hereto as Exhibit D)
It is the policy to obtain a consent from the patient in certain situations where an Authorization is
not otherwise required and as summarized in the Guidance on Consents and Authorizations
Observers in the Operating Room (attached hereto as Exhibit E) and Guidance on Consents and
Authorizations for Photography or Videotaping (attached hereto as Exhibit F).
PURPOSE: The purpose of the policy is to implement certain aspects of Catholic Healthcare
West’s (CHW) Privacy Principles (110.1.001) in order to comply with the Health Insurance
Portability and Accountability Act (“HIPAA”) and other federal and state laws governing
protection of confidential health information. The CHW Board has delegated certain of its
authority to the CHW Chief Privacy and Data Security Administrator to ensure that necessary
policies and procedures are written and implemented to comply with the Privacy Principles.
89
Patient Confidentiality, Use and Disclosure of protected Patient Health
Information (PHI)
POLICY: It is the policy of Saint Francis Memorial Hospital (SFMH) to comply with the
Federal Health Insurance Portability and Accountability Act privacy regulations (HIPAA Privacy
Rule, effective Apri/1, 2003) and all California laws and regulations that pertain to the
confidentiality, use and disclosure of PHI (described in detail in Definitions, Section IV). SFMH
employees and physicians will respect patients' confidentiality rights and PHI will only be used
or disclosed in compliance with the applicable laws and regulations.
PURPOSE: To ensure the protection of Patient Health Information, and provide a guideline
for the fundamentals on how to make sure that all policies are understood by staff.
PROCEDURE:
A. Obtain Prior Written Consent: Except as described in Sections C & D below, SFMH will
obtain written patient consent before using or disclosing PHI for purposes of carrying out
treatment, payment procedures or hospital operations related to the patient's care (collectively
referred to as "TPO," each term is individually defined in Section IV).
1. One consent covers all uses and disclosures for TPO by SFMH indefinitely 2.
SFMH providers may condition provision of treatment on the individual
providing consent 3. Effective Apri/1, 2003, each consent document must
inform the individual that he/she has the opportunity to review the CHW Notice
of Privacy Practices prior to signing the consent. HIPAA does not require that
the individual read the notice before the consent is signed.
B. Notice of Privacy Practices: Effective Apri/1, 2003, SFMH will provide all patients with
CHW Notice of Privacy Practices as required by the HIPAA Privacy Rules. Copy of CHW
Notice of Privacy Practices, Attachment A.
C. Disclosure & Use of PHI Without Consent: SFMH may disclose or use or use PHI without
prior consent:
1. in an emergency.
2. when a SFMH provider is required by law to treat the patient.
3. when treatment is medically necessary and substantial communication barriers would
create unsafe or unreasonable delays in rendering necessary treatment.
D. Disclosure & Use of PHI by Verbal Agreement: For the following limited purposes, SFMH
may disclose PHI if the individual has an opportunity to agree to, prohibit or restrict the
disclosure. No written consent or authorization is required so long as the individual is informed
in advance of the use or disclosure and is granted a meaningful opportunity to decide whether to
give permission. The three circumstances are use and disclosure as follows:
1. For the SFMH directory, i.e. to the SFMH Chaplain, Clinical Pastoral Education
residents, members of the clergy or to other persons who ask for the individual by name.
90
2. For involvement in the individual's care to next-of-kin, family members and close
personal friends. A valid disclosure is limited to PHI that is directly relevant to that person's
involvement with the individual's care (or payment for that care). If the patient is not present or
is incapacitated and verbal agreement cannot be practicably provided, the SFMH provider still
may decide to disclose PHI to next-of-kin, family members and friends if, in his/her professional
judgment, the heath care provider believes such disclosure is in the best interests of the patient.
3. For notification purposes, i.e notifying or assisting in the notification of a family
member, a personal representative of the individual or another person responsible for that
individual's care about the individual's location, general condition or death.
E. Additional Disclosure & Use of PHI Requires Authorization: If SFMH uses or discloses PHI
for any purpose other than TPO, SFMH will obtain a valid authorization whenever required by
the HIPAA Privacy Rule and California law and regulations.
1. Revocation of Authorization: An individual may revoke an Authorization at any time,
so long as the revocation is in writing. Unless a SFMH provider has taken some action in
reliance upon the Authorization, the Authorization is effectively revoked.
F. Deceased Persons: The health information of deceased persons is subject to the same
protections as that of Jiving persons. The deceased person's beneficiary or personal
representative may authorize the use and disclosure of the deceased person's PHI.
G. Minors: (individual under the age of 18 years of age). Generally, a minor's parent or guardian
acts on his or her behalf for purposes of the privacy rules.
Minors, however, may act on behalf of themselves if the parent or guardian agrees, or if the
minor has consented to the health care service, and no other consent is necessary, or any other
necessary consent has been obtained, i.e. court order. A minor's parent or guardian may not
authorize the release of a minor's PHI if the minor consented to the treatment as allowed by state
law and federal regulations.
H. Employment Determinations: Authorization is required to use or disclose an individual's PHI

for employment determinations. For example, a provider must have the individual's authorization
to disclose the results of a pre-employment physical or any drug toxicology testing to an
individual's employer.
I. Restrictions: Individuals have the right to request restriction of uses and disclosures of their
PHI. Saint Francis will respect this right and will:
1. Permit an individual to request that SFMH restrict:
(a) Uses or disclosures of PHI about the individual to carry out treatment,
payment or health care operations.
(b) Disclosures to others, including family members and friends.
2. SFMH is not required to agree to the requested restrictions. If the individual who
requested the restriction is in need of emergency treatment and the restricted PHI is needed to
provide emergency treatment, SFMH may use or disclose the restricted PHI to provide such
treatment to the individual
Procedures for Special Patient Groups
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J. Mental Health Records: Release of Mental Health and Developmental Disability Information
Covered by the Lanterman-Petris-Short Act
1. Applies to all information and records obtained in the course of providing services to
patients who are involuntarily treated or evaluated and patients who are voluntarily treated for in
the SFMH psychiatric department.
2. An authorization must be obtained for each separate disclosure and/or use.
3.The elements of the patient authorization for release are statutorily defined and are
contained in the form "Authorization to Use or Disclose Protected Health Information
Under LPS Act." 3. Any information disclosed with the patient's (or legal representatives)
authorization must be accompanied by a statement that prohibits further disclosure unless
the authorization expressly permits further disclosure or the disclosure is otherwise
permitted by the federal regulations.
4. For these patients, PHI may be released upon the patient's written authorization only to
the persons listed below:
a. The patient's attorney, if the patient is unable to sign, the facility may release
records to the attorney, if the staff has determined "that the attorney does represent the
interests of the patient".
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Release of Medical, Psychiatric, alcohol/substance Abuse and HIV
Information
POLICY: The patient record is the property of the hospital. The original patient record
should not be removed from the hospital premises or jurisdiction except by statute, subpoena, or
court order.
Patient record information shall be released only through authorized personnel in order to protect
the confidentiality and security of such information within an appropriate timeframe.
A legible, written, dated and signed authorization from the patient, parent, legal guardian or
executor is required when patient records are released to or reviewed by non-staff physicians,
other health care facilities, attorneys, insurance companies, or for state disability with the
exception of the following:
St. Francis Memorial Hospital Medical Staff members treating the patient; hospital staff with a
legitimate need for access;
Health care facilities to which the patients are directly transferred from St. Francis for
continuation of care and other health care providers with an active and current patient
relationship;
Worker's Compensation;
Lumetra
Appropriate government agencies; e.g. the Examiner/Coroner, Dept of Public Health, and when
disclosure is specifically required by law;
CHW Business Office;
Authorized financial audits;
Nursing students with proper authorization
Hospital contact insurance companies , e.g. Blue Cross;
Hospital's legal representatives.
A legible, written, dated and signed psychiatric, alcohol/substance abuse or HIV authorization
from the patient, parent, legal guardian or executor is required when psychiatric,
alcohol/substance abuse of HIV records are released.
Request for access to patient records for bona fide study and research will be referred to the
Institutional Review Board for approval.
PURPOSE: To protect sensitive information involving psychiatric, and/ or substance abuse

among patients, staff, and HIM.
PROCEDURE:
REQUESTS FOR PATIENT INFORMATION
• Request for copy of Face Sheet from treating physicians or their office staff:
• Obtain specific patient information from the requester
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• First and last name
• Date of birth
• Social security number
• Print facesheet from the computer
• Type in Patient name in Lastword
• Left click on Patient Information
• Double left click on Faceadm-Print admission (inpatient ) facesheet or OP-Print
outpatient facesheet
• Scroll and select
• Left click on Select Account
• Send/fax printed facesheet
• Request for discharge dates over the telephone from patients’ insurance company:
• Obtain specific patient information from the requestor
• First and last name
• Date of birth
• Social security number
• Type in patient name in Lastword -Patient Look Up
• Left click on MPIDX tab
• Scroll and select
• Double left click
• Give the information over the telephone
Guidelines
• Patient demographic information, admission/discharge dates and discharge disposition

can be released with a proper authorization.
• The following basic information can be released without a proper authorization IF the
information is requested using the patient name AND IF the patient has not opted out of
the facility directory:
• Location within the hospital
• General condition of the patient
• Religion (to clergy)
MEDICAL INFORMATION
• Gather all incoming mail for release of information from the basket
• Open the mail
• Staple multiple pages and return envelope
• Discard outer envelope if there is a return envelope
• Stamp received date
• Process incoming request
94
• Check patient name, birth date or social security number, and date of treatment, and type
of information requested.
• Make and forward a copy of the request to Risk Management on potential lawsuit
• Check for a proper authorization
• Guidelines:
• The authorization must be dated and signed by the patient, parent or conservator of the
patient's person, legal guardian of a minor patient, or by the personal representative or
beneficiary of a deceased patient, or executor.
• The authorization must be in writing in at least 14-point type (Civil Code Section 56.11)
or legibly handwritten by the person who signs it.
• The authorization must be clearly separate from any other purpose addressed on the same
page, and can serve no other purpose than to execute the authorization.
• The authorization must describe each and every purpose of the requested use or
disclosure (if the request is initiated by the individual, it is sufficient to put "at the request
of the individual") and its limitations by the person/entities authorized to receive the
medical information.
• The authorization must include the name or function of the provider of health care that
may disclose patient health information.
• The authorization must include the name of or function of the persons or entities
authorized to receive the patient health information.
• The authorization must include a specific date when the authorization expires.
• The authorization must include a statement of the individual's right to revoke the
authorization in writing including exceptions and an explanation of how to obtain
revocation.
• The authorization must include a notification to the individual that such information
disclosed pursuant to the authorization may be re-disclosed by the recipient and, if so, it
may no longer be protected by federal confidentiality law if the recipient of the health
information is not a covered entity subject to such federal confidentiality law.
• The authorization must include a statement that certifies that the individual has received a
copy of the authorization.
Guidelines: If proper authorization is not available, return the request with form letter (See
attached). Refer to the CHA Consent Manual if questions rise or contact the CHW corporate
attorney.
• Look in the computerized MPI system

• Compare the admission date with the date on the authorization to assure that the
authorization does not predate admission
• Write the medical record number, type of service and discharge dates in the upper right
corner of the request; preferably in red ink
• Return the request with the form letter, if no record is found (see form attached)
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• Forward the request as appropriate to the departments housing the requested medical
records:
• Laboratory reports to Laboratory
• Radiology reports/films to Radiology
• Billing requests only to CHW Business Office
• Physician's office records to St Francis medical staff
• Center of Sorts Medicine, Walnut Creek records to Walnut Creek; Corte Madera records
to Corte Madera center
• Note:
• Outpatient department, business office and medical staff will follow-up on these requests
• Forward a copy of the request to the Business Office when request asks for billing
information in addition to medical records.
• Request record from outpatient department/clinic by completing and faxing the form(see
attached)
• Sports Medicine in San Francisco
• Spine Clinic
• Physical/Occupational Therapy
• Melanoma Clinic
• Wound/Burn Clinic
• EKG/EEG
• Franciscan Treatment Center
Note:
Health Information Management department will make the following notes on the request
Date of request for records
From __________ outpatient department/clinic.
• Outpatient department/clinic will forward the record to Health Information Management
department in an appropriate timeframe.
• Health Information Management department will follow-up on the request for the
outpatient department/clinic records.
• Enter the request in the release of information system (e-smart log)

• Health Information Management department will make the following notes on the request
Date of request for records
From __________ outpatient department/clinic.
• Enter the request in the release of information system (e-smart log)

• Requester
• Patient name
• Medical record number
• Notes (type of records, problems)
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Incoming and Outgoing Mail
POLICY: The incoming mail shall be sorted and distributed accordingly. The outgoing mail
shall be placed in the tray for pick up and processing by the mail room.
PURPOSE: To preserve an efficient process of sorting and distributing incoming mail, as

well as ensuring outgoing mail is delivered in a timely manner.
PROCEDURE:
1. Outgoing Mail
a. Inter-office US Postal/ Courier
i. Prepare and interoffice/ St. Francis Memorial Hospital Logo envelope
1. 900 Hyde St
2. 909 Bush St
3. 1199 Hyde St
4. Others
5. 333 Main St., Redwood City
ii. Place on the tray for pick up and processing by the mail room
b. united Parcel Services (UPS)

i. fill out the UPS shipping document
ii. place shipping document in the plastic zip lock envelope
iii. insert in cardboard envelope
iv. Bring to loading dock for UPS to pick up
c. Certified/ Registered Mail

1. fill out the appropriate forms
2. Incoming Mail
a. Retrieve the incoming mail from the tray
b. Sort mail into the following piles
1. letter/ packages/ magazines
a. Manager
b. Incomplete record coordinator
c. Data quality coordinator
d. Health information coordinator
e. Health information clerk
f. Receptionist
g. Cancer registry
h. Release of information coordinator
2. ancillary reports
 inpatient
 emergency
 outpatient
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3. memos
 Manager
 All employees
4. Monthly Calendar
5. Employee Newsletter
6. Computer printout
c. Distribute the mail accordingly
1. Place in the tray manager, data quality coordinator, cancer registry door
tray
2. Place on the staff’s desk
3. Place in the release of information request basket
4. Place in the inpatient/ emergency services/ outpatient for filing basket
5. Post on the bulletin board
d. Redirect the mail when necessary
Note: If the mail is addressed to Health Information Management Services, open and determine
as to where to distribute. If the mail (envelope) is marked “CONFIDENTIAL” do not open.
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Ordering Supplies
POLICY: Office supplies shall be ordered as need by Health Information Management
Services, Word Processing and Cancer registry
PURPOSE: To ensure employee access to supplies in Health Information Management and

to provide guidelines at to how to acquire supplies.
PROCEDURE:
 In-house Store Room/ Central Processing & distribution
 Inventory supplies to see what is needed/low/missing

 Look in the supplies cabinets (e.g. band aids. Alcohol pads,
facial tissue, aspirin)
 Make inquiries of the Health Information Management
Services Personnel
 Complete the order requisition form (see attached)
 Keep track of what was ordered by retaining a copy of the
order form
 Deliver the completed and approved form to Store Room or
Central Processing and Distribution
 Obtain the approval from the Supervisor/ Manager
 On-Line Ordering of Office Supplies
 Inventory supplies to see what is needed/low/missing that

are not on stock in the storeroom of Materials Management
 Review the Boise Cascade Office Products Catalogue
 Look up for the product number and description
 Complete an office supply requisition form (see attached)
 obtain approval from the manager
 fax to Boise Cascade at 1-800-572-6473
 keep track of what was ordered by retaining a copy of the
requisition form
 Sign for the ordered office supplies into the appropriate
storage cabinet or give the office supply to the requester
 leave returned office supplies on the counter with
packaging slip for pickup on credit or exchange items
 Form (Logo Items) - Tully- Wihr Purchases
99
 Inventory to see what forms are needed/low/none
 Complete a form requisition request (see attached)
 Obtain approval from the manager
 fax to Tully- Wihr at (510) 487-8917
requisition form
 check off the received form from Material Management
and store away the forms into the appropriate storage
cabinet or give the forms to the requester
 notify Tully- Wihr of problems
 Other (outside Vendors) - Go through Purchasing – Denzel
 Complete a purchase requisition worksheet for (see

attached)
 Obtain the approval from the cost center manager and/ or
director
 Place order with vendor by SF buyers
 Return a copy of the purchase requisition to the requester
requisition form
 Check off the received order from Material Management
and store away into the appropriate storage cabinet or give
to the requester
 notify SF buyers of problems or questions
 Sort and hold the problem requests in a folder

 Locate and pull the records daily for copying by the in-
house copy service or HIM staff. Charts may be located in
the following locations:
 HIM Department
 Basement File Room
 Off-site Storage
 Compare the signature on the authorization with the
signature on the Conditions of Admission or other consent
in the medical record for any obvious variations.
 Screen the medical record thoroughly for any protected
documentation (HIV, alcohol/substance abuse and
psychiatric treatment records)
 Guidelines:
 Require a specific authorization to release psychiatric, HIV
and alcohol/substance abuse treatment records.
 Obtain a completed and signed caregiver approval form
from the patient's treating psychiatrist for the release of
100
psychiatric treatment records with the exception of requests
from patient's attorney or other health care providers for
mental health facilities.
 Remove the protected information from the record if no
specific authorization or approval from the psychiatrist is
obtained.
 If patient access is denied, inform the patient of the medical
record access denial in writing and attach a copy of the
authorization from so the patient may designate a licensed
physician, social worker, clinical psychologist or his/her
attorney to inspect the record and/or obtain copies.
 File request and caregiver approval form/denial letter in the
patient's chart on the left side of the folder.
 Document the records release in the patient's chart on the
left side.
 Place the stack of records in terminal digit order for

copying by the in-house copy service.
 Note: Hold record out for 24 hours.
 Photocopy the request

 Photocopy the requested information from the medical
record
 Write on the original request
 Copy Date
 Name of individual copying
 Itemize portions of chart that were copied
 File original request in the chart on the left side. If no
chart, e.g. ER, or Physical Therapy, staple the request in the
back of the ER or PT record.
 Enter information into the release of information system (e-
smart log).
 The in-house copy service will

 Determine and bill for clerical, copying and postage fees.
 Guideline:
 Do not bill other hospitals, physicians, business office or
government agencies.
 Fees for providing patient access to copied records are 25
cents per each page provided plus postage fees. No
retrieval fee will be charged.
 Prepare an envelope
101
 Place and seal the copies and bill in the addressed
envelope.
 Place the envelope in the outgoing mail basket.
 Hospital HIM Staff will:

 File the record in the appropriate location
 Return the record to the department/clinic:
 Label, bundle and put on the counter for pick-up by the
appropriate dept/clinic.
 Enter the date of the chart return to the dept/clinic into the
release of information system (e-smart log).
 Check on the status of a request in the release of
information system (e-smart log).
 Click Edit Request
 Type in name, medical record number or login ID
NOTE:
The Confidentiality of Medical Information Act (Civil Code section 56 et seq.) (referred to
herein as the "Act") governs the release of patient-identifiable information by hospitals and other
healthcare providers. It establishes protection to preserve the confidentiality of medical
information and specifies that a heath care provider may not disclose medical information or
records unless the disclosure is authorized by the Act, by other laws, or by the patient in
accordance with the requirements of the Act.
Upon presentation of a written authorization by an attorney or his or her representative, a

hospital or other provider m0ust make all the patient's records under its custody or control
available for inspection and copying by the attorney or attorney's representative (Evidence Code
section 1158). The patient, parent, legal guardian or executor prior to release of medical records
must sign written authorization. No copying may be done by the hospital when the requesting
attorney has employed a professional photocopier (as identified in business and Professions Code
section22450) as his/her representative to obtain the records on the attorney's behalf. Comply
with the request within five (5) working days after the request is received. A HIPAA compliant
authorization is not required.
No information may be released regarding psychiatric, alcohol and/or substance abuse patients,
not even an acknowledgement that such a patient is present in the hospital. The Lanterman-
Petris Short Act of the Welfare and Institutions Code section 5328 delineates the particulars
required for release of such psychiatric information. Records containing information pertaining
to substance abuse are subject to special protection under federal statute, 42 U.S.C. section
290dd-2 and under federal regulations found in "Confidentiality of Alcohol and Drug Abuse
Patient Records, : 42 C.F.R. part 2.
Subpoenas involving psychiatric, alcohol and/or substance abuse patient information shall be
handled in strict accordance with the Lanterman-Petris Short Act (LPS), federal statutes and
regulations, which restrict the circumstances under which the protected information may be
released without patient authorization.
102
Subpoena or court order involving HIV testing, results and/or treatment shall be handled in strict
accordance with state and federal regulations. No information shall be released unless the
patient consents by signing a specific authorization (Health and Safety Code section 120980).
TELEPHONE REQUEST FORM INFORMATION
 Ascertain the identity of the caller and his/her legal right to the requested information per
this policy.
 Request a faxed request for information specifying the following:
 Requesting Facility/Organization
 Name of Requestor
 Patient Name
 Birth date
 Admission/Discharge Dates
 Specific documents requested
 Purpose for the request
 Fax Number
 Telephone Number
 Look up the medical record number in the MPI
 Locate and pull the record
 Order the record from off-site storage if necessary. In a medical emergency exists,
request the record STAT.
 Notify the requestor that record is off-site and release will be delayed unless there is a
medical emergency involved.
 Release the information by fax.
 Make and file a note in the record regarding the release.
 Date
 Requester
 Itemize information released
 Refile the medical record.
Guidelines:
A proper authorization for emergency or continuing health care is not required.

Psychiatric, alcohol/substance abuse and HIV treatment information is particularly sensitive.
Releasing this information in a non-emergency situation requires authorization from the patient,
parent, legal guardian or executor.
Medical information should not be read to requestor over the telephone by an HIM employee.
Requested information should be conveyed via fax. In medical emergencies for which
circumstances don’t allow for faxing, refer the call and the medical record to the nursing
supervisor. The nursing supervisor may convey the information.
INTERNAL FINANCIAL AUDITS
103
Requests for financial audits may be mailed, faxed or emailed from the CHW Business Office or
Finance Dept. Requests should contain:
Patient name
Medical Record Number (if available)
Service Dates
Auditor Information (Name, company, address, telephone number)
 Look up the medical record number in MPI if necessary

 Locate and pull the medical record
 Notify the auditor that the record is ready for review, date and time of the review, and
location of the review.
 Photocopy the record if needed
 Write the review date/time, name of the auditor and itemization of what was
reviewed/copied on the audit request.
 File the audit request in the medical record
 Refile the medical record
FINANCIAL/CLINICAL AUDITS BY INSURANCE COMPANY
 Requests for financial/clinical audits may be mailed, faxed or emailed from the CHW
Business Office or Financial Dept. Requests should contain:
 Patient name
 Medical Record Number (if available)
 Service Dates
 Auditor Information (Name, company, audit date, telephone number)
 Look up the medical record number in MPI if necessary
 Locate and pull the medical record
 Keep the medical record on the audit shelf.
 Place a label on the outside of the chart with a "Post-It" stating the auditor's name an
audit date.
 Notify the auditor of the date, time and location of the review.
 The Business Office will inform the HIM dept of the audit fee. (The fee is generally
$150 or higher depending on the insurance contract.) NOTE: Route the check to the
hospital cashier for deposit in the general account #220.
 Write the review date/time, name of the auditor and itemization of what was
reviewed/copied on the audit request.
 File the audit request in the medical record.
Guidelines:
• If the patient is a member of a group having a contract with the hospital, a proper
authorization is not required.
• If the patient has signed an authorization for release of information with the insurance
company, another authorization is not required.
104
• For insurance company audits, obtain clearance from the Business Office.
SFMH NURSING/PHYSICIAN/OTHER DISCIPLINES REVIEW
 Ascertain that the requestor has legitimate access to the record.

 Obtain specific patient information:
 Patient name
 Medical record number (if available)
 Service dates
 Birthdate
 Lookup in the MPI.
 Locate and pull the medical record.
 Review and make copy for nursing, physician or other disciplines for patient care or
patient care studies.
Guidelines:
Does not require a patient authorization.
Require a note from the nursing manager/director/supervisor for record access by nursing
students.
RESEARCH PROJECTS
Guidelines:
Access to medical records for bona fide study and research will not be granted without approval
of the Institutional Review Board (SFMH Medical Staff Rules & Regulations).
HOSPITAL LEGAL REPRESENTATIVES
Guidelines:
In cases involving liability or compensation, information from the record can be released without
a proper authorization to the hospital's legal representatives.
ADMINISTRATIVE HOLD
Refer to the Policy and Procedure re: Administrative Hold.
FAXING INFORMATION
Refer to Policy and Procedure re: Faxing Information
105
RECORD COPYING FOR BILLING PURPOSES
Refer to Policy and Procedure re: Record Copying
PATIENT ACCESS
Refer to Policy and Procedure re: Patient Access
REQUESTING MEDICAL RECORDS FROM OTHER HOSPITALS
Obtain a proper authorization for release of information from the patient, parent, legal guardian
or executor. In case of a medical emergency, an authorization is not required.
Fax or mail the request to the other hospital.
File the authorization in the medical record.
When medical records pertaining to in-house patients are received in the HIM department, fax or
deliver the records to the appropriate nursing unit. File faxed copies received for discharged
patients in the medical record.
Guideline: Do not email protected health information to email addresses that are external to the
CHW system; e.g. email only to "@chw.edu" email addresses.
106
Problems with Work Equipment, Office Furniture, Work Area
POLICY: Each employee is responsible for reporting problems with work equipment,
furniture and work area to the appropriate department to ensure a safe and better working
environment
PURPOSE: To ensure that every employee has the ability to succeed in the work
place while maintaining a comfortable, productive work environment. The policy provides a
guideline in how to troubleshoot issues with office equipment, office furniture, and the work
area.
PROCEDURE:
Copy Machine
1. Trouble shoot internally

2. If unable to resolve problem, notify manager
3. Place service call
Dell Computer, HP printer, Software application, and Meridian Telephone System
1. call Help Desk at extension 64900 or email ISREQUEST

2. Identify yourself, department
3. Report the problem
4. Resolve the problem over the phone
5. Get a ticket number
Work Areas e.g. burned out light, furniture problems, etc.
1. Fill out the work order for Non-STAT problems

2. Obtain approval from manager
3. retain white copy of work order
4. Send to engineering Department through interoffice mail
5. Follow-up by engineering Department
6. Discard white copy of work order after the completion
107
Administrative Closure of Incomplete Medical Records
POLICY: It is the policy of the Health Information Management Department of Saint Francis
Memorial Hospital (SFMH) to make every effort to ensure that medical records are completed in
accordance to the time frame delineated in the Bylaws of the Medical Staff prior to placement in
permanent file. If a physician permanently leaves SFMH without completing all medical records,
completion will be obtained via mail correspondence or the records may be administratively
closed by the authority of the Health Information Management Director and the Hospital Chief
of Staff.
PROCEDURE: Members of the SFMH medical staff are required to complete medical
records electronically in Cerner PowerChart and also on the paper for the paper portion of
medical record. In the event that a physician is not able to authenticate a dictated report(s) or
handwritten orders in this way, he/she will be asked to sign the paper document(s). The signed
document(s) will be filed in the paper medical record. The following statement will be added to
the electronic dictation in Cerner PowerChart., “Signed document is in the paper medical
record.”
If a physician leaves SFMH with incomplete paper (hard copy) medical records and can be
contacted, a copy of the incomplete portions of the record will be sent by registered mail to the
physician for completion. A prepaid return envelope is included and the physician is asked to
return the completed records within 72 hours of receipt.
If an alternate physician has or can be identified, the record (hard copy or Electronic Medical
Record--EMR) may be reassigned for completion.
If the physician dies, cannot be contacted, an alternate cannot be identified, or there is indefinite
protracted physician absence, the incomplete records will be reported to the physicians
Department Care Evaluation Committee for recommendation to remove the records from
incomplete status. The HIM Director and the Chief of Staff, who have the authority to remove
the records from incomplete status and deem them suitable for permanent record storage, shall
remove the records from incomplete status by execution of the Declaration of Complete Record
(Administrative Closure) form which will be placed in the front of the paper medical record or as
an addendum in the EMR. The following addendum will be added to the deficient document –
“This record has been Administratively closed – See the Declaration of Complete record form.”
Approvals (as applicable) Approval date Approvals (as applicable) Approval date
HIM Department Nov. 2, 2009
Past approval dates:
108
Declaration of Complete Medical Record
For EMR
Exhibit A
Patient Name:
Medical Record Number:
Dates of service:
Date of declaration:
It is the policy of Saint Francis Memorial Hospital that standard documentation and record
completion components are included in the medical record before it is declared complete. Under
extenuating circumstances, this supplemental policy is instituted.
Under the circumstances of (name the circumstances such as physician death, indefinite
protracted physician absence), this record has been declared complete for filing purposes. It is
considered to be a complete medical record for purposes of Saint Francis Memorial Hospital
business.
List incomplete record components:
___________________________________ ___________________________________
Barbara Farris, RHIT, CCS Date Patricia Galamba, MD Date
Director of Health Information Management Chief of Staff
This form is considered part of the permanent medical record. It is to be released with any
record release requests when incomplete medical record portions are requested.
109
For Paper Record
Exhibit B
Patient Name:
Medical Record Number:
Dates of service:
Date of declaration:
This medical record has been administratively closed.
Under the circumstances of (name the circumstances such as physician death, indefinite
protracted physician absence), this record has been declared complete for filing purposes. It is
considered to be a complete medical record for purposes of Saint Francis Memorial Hospital
business.
___________________________________
__________________________________
Bobbi Farris, RHIT, CCS Date Patricia Galamba, M.D. Date
Director of Health Information Mgmt Chief of Staff
110
This form is considered part of the permanent medical record. It is filed above the face sheet
and is to be released with any record release requests when incomplete medical record portions
are requested.

Patient Name: Manwaring, Mark

Medical Record Number: 03076121
Dates of service: 07/27/0- – 07/27/09
Date of declaration: November 23, 2009
This medical record has been administratively closed.
Under the circumstances of Resignation from Medical Staff, this record has been declared
complete for filing purposes. It is considered to be a complete medical record for purposes of
Saint Francis Memorial Hospital business.
Signature on Anesthesia by Non-Anesthesiologists Flowsheet
___________________________________
__________________________________
Barbara Farris, RHIT, CCS Date Patricia Galamba, MD Date
111
Director of Health Information Management Chief of Staff
Abbreviations and Symbols

POLICY : Standard abbreviations are used by clinical staff to assure accurate communication
and documentation in patient medical records.
PROCEDURE:
Use only abbreviations that are contained in either of the following documents:
List of Acceptable Abbreviations (See Appendix A of this policy.) Access to this listing is also
available in Chapter IX of the on-line Patient Care Manual.
OR
On-Line Version of Stedman’s Abbreviations, Acronyms and Symbols; Third Edition. (Access
on-line Stedman’s software via the Stedman’s icon on any hospital network PC.)
Multiple terms may be associated with each abbreviation. Such abbreviations should be
interpreted within the context of the documentation.
Do not use the following abbreviations:

Abbreviation Potential Problem Preferred Term
U (for unit) Mistaken as”0”(zero), the Write "unit"
number “4” (four), or “cc”
IU (for International Unit) Mistaken for IV (intravenous) Write "International Unit"
or the number 10 (ten)
Q.D., QD, q.d., qd (daily) Mistaken for each other. The Write "daily" and "every
Q.O.D., QOD, q.o.d, qod period after the Q can be other day"
(every other day) mistaken for an "I" and the
"O" can be mistaken for an
"I"
Trailing Zero (X.0 mg), Decimal point is missed Write X mg , and always
Lack of Leading Zero use a zero before a decimal
(.X mg) or use of slash in point (Write 0.X mg)
place of the decimal point.
MS Can mean morphine sulfate or Write "morphine sulfate"
magnesium sulfate
MSO4 or MgSO4 Confused for one another Write "magnesium sulfate"
µ g (for microgram) Confused for milligram Write “mcg”
Department/Sponsoring Committee: Medical Record Documentation Review Committee

Approvals (as Approval date Approvals (as applicable) Approval date
applicable)
Department/Sponsor December 3, Medical Executive
Committee 2009 Committee
112
Leadership Council June 2008 Board of Trustees
Past approval dates: 08/18/05, 03/27/08
APPENDIX A
SAINT FRANCIS MEMORIAL HOSPITAL
LIST OF ACCEPTABLE ABBREVIATIONS
(SEE ALSO: Stedman’s Abbreviations, Acronyms and Symbols; Third Edition)
-A-
_
a before
@ at
A assessment (SOAP)
A(circled) assist
A2 aortic second sound
AAL anterior axillary line
AAROM active assisted range of motion
Abd abduction
abd. abdomen
ABG arterial blood gas
abort. abortion
a.c. before meals
AC>BC air greater than bone conduction
accom. accommodation
acid p’tase acid phosphatase
ACL anterior cruciate ligament
AD assistive device
ADA American Dietetic Association
Add adduction
Adj adjustable
ADL activities of daily living
adm. Admission
ADM abductor digiti minim
AdP adductor pollicis
A/E above elbow
AIDS acquired immune deficiency syndrome
AF afebrile
A Fib atrial fibrillation
AFO ankle-foot orthosis
AJ ankle jerk
AK above knee
AKA above knee amputation
113
alk. p’tase alkaline phosphatase
alb. Albumin
ALS amyotrophic lateral sclerosis
AM morning
Amb ambulation
Amp amputation
AMS altered mental status
amt amount
Ant anterior
A&O alert and oriented
AODM adult onset diabetes mellitus
aort. regurg. aortic regurgitation
AP antero posterior
APB abductor pollicis brevis
APL abductor pollicis longus
APIS antero posterior iliac spine
approx approximately
appt appointment
ARF acute renal failure
AROM active range of motion
ART active release technique
AS aortic stenosis
ASAP as soon as possible
ASCVD ateriorsclerotic cardiovascular disease
ASHD atherosclerotic heart disease
ASIS anterosuperior iliac spine
Asp aspiration
Assist assistance
as tol. as tolerated
A.T. achilles tendon
at. fib. atrial fibrillation
ATN acute tubular nephrosis
Aud auditory
Aud Haluc auditory hallucinations
Audio audiogram
A-V arteriovenous
AVN avascular necrosis
-B-
B both
B>A bone grater than air
B&B bowel and bladder
BB back bend
BC>AC bone greater than air conduction
BAD bipolar affective disorder
114
Bal balance
baso. basophile
B+C board and care
b.c. blood culture
BE barium enema
B/E below elbow
bet. between
BIBA brought in by ambulance
bid twice a day
Bilat – or – B (circled) bilateral
BLE bilateral lower extremities
BUE bilateral upper extremities
bili. bilirubin
BiPAP bi-level positive airway pressure
biw twice a week
BK below knee
BKA below knee amputation
bldg building
BM bowel movement
BMC body mechanics counseling
BMI body mass index
BO bowel obstruction
BOS base of support
BP blood pressure
BPM breaths per minute
BR bathroom
BRP bathroom privileges
BS bowel sounds
B.S. bed scale
B/S bedside
BSC bedside commode
BTB back to bed
BTE Baltimore Therapeutic Exercise machine
BUN blood urea nitrogen
br. sounds breath sounds
bx biopsy
-C-
C(1-7) cervical segments

°C degrees Celsius
_
c with
Ca calcium
CA carcinoma
CABG coronary artery bypass graft
115
CAD coronary artery disease
cal calories
calct calorie count
CAPD continuous ambulatory peritoneal dialysis
CAT computerized axial tomography
cath. catheter
CBC complete blood count
CBS chronic brain syndrome
CC chief complaint
CCU coronary care unit; critical care unit
CG; CGA contact guard; contact guard assist
CGU Come & Go unit
CHD coronary heart disease
CHF congestive heart failure
CHD coronary heart disease
CHI closed head injury
chol. HDL cholesterol high density lipoprotein
CL clear or clear liquid
CLOF current level of function
Cl chloride
cldy. cloudy
centimeter
CMC carpometacarpal joint
CNS central nervous system
c/o complaints, complains of
CO carbon monoxide
CO2 carbon dioxide
Comm communication, communicative
Conc. Concentric; concentrated
cont continued
cog cognition, cognitive
contralat contralateral
conc. concentrated
COPD chronic obstructive pulmonary disease
COTA certified occupational therapist
CP central pressure; cold pack
C.P. chest pain
CPAD continuous positive airway pressure
CPM continuous passive motion
CPR cardiopulmonary resuscitation
CPT chest physiotherapy
CRA crackles
C-Spine – or – C/S cervical spine
CSF cerebrospinal fluid
C/R contract relax
creat. creatinine
116
CRF chronic renal failure
CSR craniosacral release
CTA clear to auscultation
CT scan computerized tomography
CTSP called to see patient
CTS/R carpal tunnel syndrome / release
CTx cervical traction
CUS chronic undifferentiated schizophrenia; continuous ultrasound
CVA cerebrovascular accident
CW clockwise
CCW counterclockwise
c/w complicated with
Cx cancelled
CXR chest x-ray
-D-
DI, II, III, IV, V digits one, two, three, four, five
d. disease
D&C dilation & curettage
DAT. diet as tolerated
D/C discontinue
d/c discharge
decr. decrease
defic. Deficiency
deg degenerative
dep. dependent
dept. department
Derm. Dermatology
DF dorsiflexion
DI diabetes insipidus
Dias diastolic
DIC disseminated intravascular clotting
diff. different
DIP distal interphalangeal joint
disch. discharge
DJD degenerative joint disease
DK→C double knee to chest
dl deciliter
DM Diabetes Mellitus
Dmeth or Dex Dexamethasone
DOA dead on arrival
DOB date of birth
DOE dyspnea on exertion
DOI date of injury
DPC distal palmar crease
117
DPNS deep pharyngeal neural stimulation
Drsg dressing
DS donor site
DTR deep tendon reflex
DVT deep vein thrombosis
dx diagnosis
-E-
E. panel electrolyte panel

ea. each
EAC external auditory canal
ECF extended care facility
Ecc. eccentric
ECCE extracapsular cataract extraction
ECHO echocardiogram
ECRB extensor carpi radialis brevis
ECRL extensor carpi radialis longus
ECT electroconvulsive therapy
ECU extensor carpi ulnaris
EDC extensor digitorum communis
EDM extensor digiti minimi
edu education
EEG electroencephalogram
e.g. for example
EGS electro galvanic stimulation
EHL extensor hallucis longus
EIP extensor indicis proprius
EKG electrocardiogram
EMG electromyogram
EMS electromyelostim
EMT Emergency Medical Tech.
ENT ear, nose and throat
EOB edge of bed
EOD end of day
EOM extraocular movement
EOMI extraocular movement intact
EOR end of range
EPAP Expiratory Positive Airway Pressure
EPB extensor pollicis brevis
EPL extensor pollicis longus
epith. epithelium
equip equipment
ER emergency room
ER-or-ext. rot. external rotation
ESR erythrocyte sedimentation rate
118
ESRD end stage renal disease
E-stim electrical stimulation
ETA estimated time of arrival
ETCO2 end-tidal CO2
etc. et cetera
ETOH alcohol
ETT endo tracheal tube
EV eversion
eval evaluation
ex exercise
Ext extension
-F-
F fair (muscle grade)

F1 first filial generation
F2 second filial generation
FA functional ability
FABER flexion abduction external rotation
FADIR flexion adduction internal rotation
Fam family
FB full back
FBS fasting blood sugar
FCR flexor carpi radialis
FCU flexor carpi ulnaris
fdg. Feeding
FDM flexor digiti minimi
FDP flexor digitorum profundus
FDS flexor digitorum superficialis
Fe iron
FES functional electrical stimulation
FEV1 forced expiratory volume in 1 second
FF forward flexion
FH family history; forward head
FHP forward head posture
FiO2 fractional concentration of inspired oxygen
FL full liquid
flex flexion
fl. dr. fluid drum
fl. oz fluid ounce
flds fluids
fluido fluidotherapy
fluro fluroscopy
FN fairly nourished
for. Foreign
FPB flexor pollicis brevis
119
FPL flexor pollicis longus
freq. Frequent
ft foot/feet
FT full thickness
FUO fever of unknown origin
FVC forced vital capacity
FWB full weight bearing
FWW front wheel walker
fx fracture
Fxnl – or - Fxnl functional
-G-
g gallop
G good (muscle grade)
GA general anesthesia
Gastrocs gastrocsoleus
GB gallbladder
gen. general
GI gastrointestinal
GIB GI Bleed
Glut gluteal
Gm. gram
Gm.% grams per hundred millimeters of serum or blood
GP gastroplasty
gr. grain
Grav. I. Grav. II, etc. primigravida, secundigravida, etc. – indicating a
woman of so many pregnancies
grp group
GTT glucose tolerance test
gtt. drops
GU genitourinary
Gyn. Gynecology
-H-
H20 water
H&P history and physical
HA headache
HAART highly active antiretroviral therapy
HAB / Hor. Abd. horizontal abduction
HAD / Hor. Add. horizontal adduction
Hams hamstrings
HBB hand behind back
HBH hand behind head
HBP high blood pressure
120
HBV high biological value
Hct. hematocrit
HCO3 bicarbonate
HEENT head, eyes, ears, nose, throat
HEP home exercise program
Hgb. hemoglobin
H-H hemoglobin-hematocrit
HHA home health agency
HHN hand held nebulizer
HIV human immunodeficiency virus
HL hooklying
HME heat moisture exchanger
H/O hand out
H.O. – or – h/o history of
HOB head of bed
HOH hard of hearing
hpf high powered field
HP hot pack
HPI History of Present Illness
HR heart rate
hr hour
hs bedtime
HS hamstring
HSS hamstring stretch
HT Hubbard tank
ht height
HTN hypertension
HVGS high-voltage galvanic stimulation
HX, Hx history
-I-
I (circled) independent
I131 radioactive iodine
IBW ideal body weight
ICB intensive care burn
ICS intercostal space
ICTx intermittent cervical traction
ICU intensive care unit
I&D incision and drainage
ID internal derangement
IDDM insulin dependent diabetes mellitus
IF index finger
IFC interferential current
I&O intake and output
IM intramuscular
121
impt important
inc incomplete
incr increased
indep – or – I (circled) independent
Inf inferior
info information
inj injury
Int internal
Inter. – or – I intermittent
IOL intraocular lens
Ionto iontophoresis
Inv inversion
IP ice pack; interphalangeal
IPAP inspiratory positive airway pressure
IPPB intermittent positive pressure breathing
Ipsilat ipsilateral
IPTx intermittent pelvic traction
IQ intelligence quotient
IR -or- int.rot. internal rotation
ITB ilio tibial band
IV intravenous
IVAC infusion control device
IVP intravenous pyelogram
incr. increased
inspir. Inspiration
iso. isomentric
-J-
JCAHO Joint Commission on Accreditation of Healthcare

Organizations
JODM juvenile onset diabetes mellitus
jt joint
JVD jugular venous distension
-K-
K potassium
KA ketoacidosis
KCal energy
KJ knee jerk
KUB kidney, ureter, bladder
Kg. kilogram
-L-
122
L; lt; or L(circled) left
L-Spine lumbar spine
L(1-5) lumbar segments
LB lower body
LLE left lower extremity
LLL left lower lobe – lung
LUL left upper lobe – lung
RLL right lower lobe – lung
RML right middle lobe – lung
RUL right upper lobe – lung
LLQ left lower quadrant – abdomen
LUQ left upper quadrant – abdomen
RLQ right lower quadrant – abdomen
RUQ right upper quadrant – abdomen
lab laboratory
LAQ long arc quad
lat lateral
Lats latissimus dorsi
LB low back
lb. pound
LBP low back pain
LBQC large-base quad cane
LBS low back strain
LCL lateral collateral ligament
LDL low density lipoprotein
LE lower extremity
lg large
LH left-handed / long handled
lig ligament
LIH left inguinal hernia
ling linguistic
LLE left lower extremity
LMP last menstrual period
LOB loss of balance
LOC loss of consciousness
LOH loss of hearing
LOS length of stay
LP lumbar puncture
LS – or – L/S lumbosacral / lumbar spine
Lt left
LTG long-term goals
LTM long-term memory
LUE left upper extremity
LVN licensed vocational nurse
lymphs. lymphocyte
123
lytes electrolytes
l&w living and well
L/Min liters per minute
-M-
m murmur
M1 mitral first
M3PT middle third patellar tendon
MAC mycobacterium avium complex
MAFO modled annkle-foot orthosis
malig malignant
man manual
MAO monoamine oxidase
max maximum
MBS modified barium swallow (study)
MC manual cue
M/Cal MediCal
M/Care Medicare
MCH mean corpuscular hemoglobin
MCL medial collateral ligament
MCP metacarpal phalangeal
MCV mean corpuscular volume
mCi millicurie
MDI metered dose inhaler
mech mechanical
med medial
Med. Medicine
Med Asst medical assistant
mEq (mEq/L) milliequivalents (per liter)
met metastases
MF middle finger
MFR myofascial release technique
mg. milligrams
mg.% milligrams per hundred millileters of serum bood
Mgmt management
MHP moist hot pack
MI myocardial infarction
mid middle
MIF maximum inspiratory force
min minimum
misc miscellaneous
ml. millileter
mm muscle
MMT manual muscle test
MM/Hg millimeters of mercury
124
MN midnight
Mn Manganese
Mo month
mob mobilization
Mod moderate
MOM milk of magnesia
mono. monocyte
MCP metacarpophalangeal
MR medical record
MRI magnetic resonance imaging
MSE mental status examination
MSW medical social worker
MTPJ metatarsal pharangeal joint
MV multivitamin
MV minute volume
MVA motor vehicle accident
MVI multivitamin infusion
Mvt / mvmt movement
-N-
n nerve
N normal; neck
NL normal
N/A not applicable
Na sodium
NAD no acute distress
NAGS natural apophysial glides
NBOS narrow base of support
NBQC narrow-based quad cane
NC normocephalic; nasal canula
NDT neurodevelopmental treatment
neg. negative
Neuro neurological
NG nasogastric
NH nursing home
NIDDM non-insulin dependent diabetes
NKA no known allergies
NKDA no known drug allergies
NKFA no known food allergies
NMES neuromuscular electrical stimulation
Nml normal
no. number
noct. nocturnal
NP non-productive
npo nothing by mouth
125
NS Neurosurgery
ns normal saline
NSG nursing
NSNC no show / no call
N/T not tested
N+T numbness and tingling
N+V nausea and vomiting
NWB non-weight bearing
-O-
O objective (SOAP)
O2 oxygen
O2 cap. oxygen capacity
O2 sat. oxygen saturation
OA osteoarthritis
OBS organic brain syndrome
Obst. Obstetrics
occas occasional
OD right eye
ODM opponens digiti minimi
O/M oral-motor
Omni omnistim
OOB out of bed
OP opponens pollicis; over pressure
Op. operation
ORIF open reduction external fixation
Ortho. orthopedic
OS left eye
OT(R) occupational therapy/ist (registered)
OTI OT intern
oz. ounce
-P-
P poor (muscle grade); plan (SOAP)

_
p after; post
P2 pulmonic second heart sound
P&A percussion and auscultation
PA pulmonary artery; posteroanterior
PaCO2 partial pressure of arterial carbon dioxide
PaO2 partial pressure of arterial oxygen
PAIVMS passive accessory motion
Para I, Para II, etc. primipara, secundipara, etc. – indicating a woman of
so many children
126
paracent. paracentesis
Paw airway pressure
PB barometric pressure
PC pressure control
PBI protein bound iodine
PCL posterior cruciate ligament
PCM protein calorie malnutrition
PCP Pneumocystosis carinii pneumonia
PCU psychiatric care unit
p.c. after meals
PD postural drainage
PD Parkinson’s Disease
PE physical examination; pulmonary embolism
Ped. Pediatric
PEEP positive end-expiratory pressure
PF plantar flexion
PFD patello femoral dysfunction
Perm permanent
PERRLA pupils equal, round, reactive to light and
accommodation
pH hydrogen ion concentration
PH past history
Phono phonophoresis
PIP proximal interphalangeal (joint) or
peak inspiratory pressure
PIVM passive invertebral motion
PKB prone knee bend
PL palmaris longus
P/L pharyngeal - laryngeal
PLB pursed lip breathing
PLOF -or- PLF prior level of function
PMD private physician
PMH past medical history
PMN polymorphonuclear
pn -or- P(circled) pain
pneum pneumonia
PNF proprioceptive neuromuscular facilitation
p.o. by mouth
PO post operative
POD# postoperative day # 1, 2, 3 . . .)
pop popliteal
pos positive
poss possible
POST posterior
ppd packs per day (cigarettes)
p.r. per rectum
127
PRBC packed red blood cells
PRE progressive resistance exercise
pref preference
prep. prepare
prn as often as necessary
Prog. prognosis
PROM passive range of motion
prot. protein
pro. Prothrombin
prog. prognosis
PS paraspinals
PSH past surgical history
PSIS posterosuperior iliac spine
PSV pressure support ventilation
psych psychiatric
pt patient
PT(R) physical therapy /ist (registered)
PTB patellar tendon-bearing
PTI PT intern
PTT partial thromboplastin time
P.T.A. physical therapy assistant
PTA prior to admission
PTx pelvic traction
PUD peptic ulcer disease
PUS pulsed ultrasound
PVD peripheral vascular disease
PWB partial weight bearing
Px – or – prog. prognosis
-Q-
q each/every
qiw four times a week
qhs. every night
q. 2h. every two hours
q. 3h. every three hours
q. 4h. every four hours
q.n.s. quantity not sufficient
Q-ped quadriped
quads quadriceps
quant. quantitative or quantity
-R-
r rub
128
R – or – R (circled) right
RA room air
RR respiratory rate
rad dev / RD radial deviation
rbc red blood cell
RBC red blood count
RBS random blood sugar
RC rotator cuff
RCP respiratory care practitioner
RCT rotator cuff tear
R.D. Registered Dietitian
RDI recommended daily intake
re regarding
rec recommend
ref referred; referral
reg regular
rehab rehabilitation
restr. restriction
Resus. Resuscitation
RF ring finger
Rh Rhesus blood factor
RI right index finger
RIH right inguinal hernia
RLE right lower extremity
RN Registered Nurse
R/O rule out
RO reality orientation
ROM range of motion
ROS review of systems
rot rotation
RRE round, regular, and equal
RSBI Rapid Shallow Breathing Index
rt right
RTR return to room
RTW return to work
RUE right upper extremity
Rx prescription; treatment/rehab
-S-
S subjective (SOAP)
S -or- sup supervision
s without
S(1-5) sacral segments
S+A sugar and acetone
129
SaO2 saturated arterial oxygen %
SAQ short arc quads
SACH solid ankle cushion heels
sat. saturated
SBA stand-by assist
SBQC small-based quad cane
SBR side bend right
SBL side bend left
SCI spinal cord injury
SCM sternocleidomastoid
SCT static cervical traction
SEC seclusion
secs seconds
SF small finger
shld shoulder
SI sacroiliac
Signif -or- sig significant
SIMV synchronized intermittent mandatory ventilation
SK→C single knee to chest
SL under the tongue, sublingual; side lying
S/L speech / language
SLB short-leg brace
SLP Speech Language Pathologist
SLR straight leg raise
sm. small
SMA simultaneous multichannel analyses
SMAS superficial musculoaponeurotic system
SNAG sustained natural apophyseal glides
SNF skilled nursing facility
SOAP subjective, objective, assessment and plan
SOB shortness of breath
sol. solution
s.o.s. may be repeated once if urgently required
S/P status post
spec. specimen
sp. bath sponge bath
sp. gr. specific gravity
SpO2 saturated pulse oxygen %
SPC single-point cane
SPT static pelvic traction
S/S signs and symptoms
ss. enema soapsuds enema
S-Spine sacral spine
ST Speech Therapy /ist
Staph. staphylococcus
stat. immediately
130
STD sexually transmitted disease
std. Standard
STG short-term goals
stillb. stillbirth
stim stimulation
STM short-term memory
Strep. streptococcus
STSG split thickness skin graft
sub/subst. substitute
STJ subtalor joint
Sup superior
Surg. or surg. Surgery
SW social worker
sx symptom
sympat. Sympathetic
syn synergy
synd. Syndrome
-T-
T trace (muscle grade)

T1-12 thoracic segments
T&A tonsillectomy and adenoidectomy
TAB therapeutic abortion
TB tuberculosis
TBI traumatic brain injury
T band theraband
TBSA total body surface area
Tbsp. tablespoon
Tbc. tuberculiar
TDWB touch down weight bearing
TENS transcutaneous electrical nerve stimulation
TF tube feeding
TFM transverse friction massage
TG triglyceride
TG ex tendon gliding exercises
THA total hip arthroplasty
Ther therapeutic
Therex therapeutic exercise
THP total hip precautions
THR total hip replacement
TIA transient ischemic attack
TIBC total iron binding capacity
tid three times daily
tiw three times a week
TKE terminal knee extension
131
TKA total knee arthroplasty
TKR total knee replacement
TM tympanic membrane
TMJ temporomandibular joint
tol tolerance/tolerated
toxo toxoplasmosis
TORB telephone order read back
TP total protein; transverse process; trigger point
TPN total parental nutrition
TPR temperature, pulse, and respiration
Trap trapezius
Trng training
TSA total shoulder arthroplasty
TSR total shoulder replacement
T-Spine -or- T/S thoracic spine
tsp teaspoon
TTP tender to palpation
TTS thermal tactile stimulation
TTWD toe touch weight bearing
TURP transurethral resection of prostate
TV tidal volume
Tx treatment / therapy / traction
-U-
U – or – Unilat. unilateral
UB upper back / upper body
UBE upper body ergometer
uCi microcurie
UD unit dose
UE upper extremity
UGI upper gastrointestinal series
Uln Dev / UD ulnar deviation
uncont. uncontrolled
unk unknown
URI upper respiratory infection
Urol. or urol. Urology
US ultrasound
UT upper trapezius
UTD undetermined thickness depth
UTI urinary tract infection
-V-
vag. vagina
vasc. Vascular
132
VC verbal cue
Vit. vitamin
VC or vit. cap. vital capacity
V+M vitamin and mineral
VMA vanillylmandelic acid
VMO vastus medialis oblique
VORB verbal order read back
V/S vital signs
VSS vital signs stable
VT tidal volume
•
VE minute ventilation
•
V gas flow
-W-
WB weight bearing
WBAT weight bearing as tolerated
wbc white blood cell
WBC white blood count
WBOS wide base of support
WBQC wide-based quad cane
WBTT weight bearing to tolerance
WC Worker’s Compensation
W/C wheelchair
WD, WN well-developed, well-nourished
WFL within functional limits
wk week
WNL within normal limits
W/O without
WP whirlpool
wt. weight
-X-
X (with line over) except

Xfers transfers
-Y-
yo year old
yr. year
133
-Symbols-
No / None
♂ Male
♀ Female
↑ Increase
↓ Decrease
 Flexion
/ Extension
↑↓ Up and down
> Greater than
< Less than
∠ Angle
≈ Approximately
Change
1°, 2°, 3° Primary, secondary, tertiary
' Feet
" Inches
= Equals
# Number
? Question
° Degrees or hour
i, ii, iii One, two, three
90/90 position of 900 knee and hip flexion
+ positive/plus
negative/ minus
5/5 manual muscle grade = normal
4/5 manual muscle grade = good
3/5 manual muscle grade = fair
2/5 manual muscle grade = poor
1/5 manual m
134

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Department-Specific Scope of Service/Staffing Guidelines............................................................

DESCRIPTION OF SERVICES PROVIDED

B. CUSTOMER OR POPULATION SERVED

1. The department provides services to medical staff, nursing units,

Refer to the Performance Improvement Plan

TITLE QUALIFICATIONS RESPONSIBILITIES

A. MINIMUM STAFFING PATTERN

Title FTE Shift Days

B. CRITERIA USED TO ADJUST STAFFING LEVELS Fluctuations in the

C. PROVISION OF STAFFING DUE TO UNEXPECTED INCREASE IN

D. DELEGATION OF DEPARTMENT OPERATIONS TO ANOTHER

VI. DEPARTMENT GOALS

VII. DEPARTMENT PERFORMANCE IMPROVEMENT

The goal of Performance Improvement activities is to enhance existing processes and

Saint Francis Memorial Hospital supports and encourages a multidisciplinary approach to

Transcription Coordinator Release of Information

Guidelines for submission of request

Note: No two employees can be on vacation at the same time.

DEPARTMENTAL ROLES AND RESPONSIBLITIES

Approved By: ____________________________________ Date: ______________

List your Departmental responsibilities here:

1) Assess any damage to 1. Assess your department using the Department

____ Activate your

What to Do for an Internal Disaster:

In Case Evacuation Is Ordered: Roles of Other Departments

A copy of your Departmental Evacuation Map (also located in all

What to Do During an Earthquake:

What to Do After an Earthquake:

PRE-DISASTER DEPARTMENTAL ROLES AND RESPONSIBILITES

Planning and Mitigation Responsibilities of the Departmental Manager

Location of Basic Emergency Supplies:

Item Quantity Location Check Frequency Responsible

Recovery Activities: As soon as feasible, departmental services should be restored in

List your Departmental responsibilities here:

POLICY: Health information Management Services is responsible for implementing the

4. Perform the following for water-damaged records

5. Perform the following for fire damaged records

1. During downtime of the clinical information system, medical record numbers of

OUTPATIENTS (Emergency Room, Sports Medicine, Spine Clinic)

B. Ordering records from Off-site Storage

o Complete the fax order form

C. Returning Records to Off-site storage

o Place on shelf for returning to off-site storage

D. Purging Of Records From Department By Off-Site Staff’

E. Purging of records from the Clinics

-retrieve the discharge lists for that particular year

o Destroy the patient records by the off-site storage company

5. Responsibility for accuracy of dictation content is that of the dictating physician.

Saint Francis Memorial Hospital

1. TO ACCESS THE DICTATION SYSTEM

1 - PRE-OP History & Physical 8- ER – PATIENT ADMITTED

WORKTYPES FOR HOSPITALIST USE ONLY

TOUCH TONE CONTROLS – While Dictating

1 - Hold 7 - Backup & press 3 to playback

FOR ASSISTANCE CALL: MedQuist: (800) 747-6264 OR

PURPOSE: To provide guidelines on the process of transcribing reports and to ensure

A. Outside Transcription Services

B. Health Information Management Service

1. Retrieve the printed transcribed reports from the printer

3. Retrieve the batch copy of reports at 4 p.m.

o physicians e.g. dictation physician, carbon copy to the physician(s)

a. copies for mailing

5. Deliver the original reports

Him Official Policies & Procedures Binder

Him Official Policies & Procedures Binder

Approved By: ______________________ Date: