Health Information Management Department House Staff Orientation Location

Health Information Management Department House Staff Orientation Location: Basement of Rock Pavilion Southeast corner Broad and Ontario Streets Health Information Management Department Room A-215 Hours of operation 7 days a week 2 shifts – 7: 30 a. m. through 11 p. m. Main phone number – 2 -3755 215 -707 -3755

Resident’s Key Interaction with the HIM Department § § System Access: Alpha Imaging Chart Deficiency completion Suspension/Reinstatement Documentation § § Dictation Death Certificates Autopsy consents Gift of Life

Resident’s Key Interaction with the HIM Department § System Access: Alpha Imaging § Chart Deficiency completion § Complete dictations within xx days § Suspension/Reinstatement § 1 chart >30 days post discharge § 10+ charts >7 days post discharge

Resident’s Key Interaction with the HIM Department § Documentation § Immediate Post Op Note § Complete before level of care changes § Dictation § Operative Reports § Complete within 24 hours § Discharge Summaries Required on all admissions Completed within 30 days of discharge

IMMEDIATE POST OP NOTE ALWAYS • Complete the Immediate Post Op Note • Dictation is required on EVERY operating room procedure • Consult blue dictation card for reference if needed

Dictated DC Summary - Good

Resident’s Key Interaction with the HIM Department § Documentation § Death Certificates § Autopsy consents § Gift of Life

Completion of Death Certificates Located on all nursing units ØDeath Certificate blank and sample form ØGift of Life ØConsent to Autopsy Form ØMedical Examiner protocol ØMIS Pathway must be completed Please note The decedent’s remains cannot be released to the funeral director without the completed paperwork.

DEATH CERTIFICATE ØUse only Black ink ØNO cross-outs ØNO overwrites Øname only on side ØAbbreviations may NOT be used Øand cardiac arrest without etiology noted is NOT an acceptable cause of death!

CONSENT TO AUTOPSY FORM Most common error: Form must be signed by the physician on the witness line And Write “NONE” if there are no restrictions

Documentation Authentication: sign/date/time/contact phone # Write Legibly Abbreviations list Verbal orders signed within 24 hours in MIS

Never Use the Following Abbreviations Temple University Hospital Do Not Use Abbreviations List Do NOT use this abbreviation: Instead WRITE this: ARA-A Vidarabine ARA-C Cytarabine IU International Unit MGS 04 Magnesium Sulfate Mental Status, Multiple Sclerosis, Morphine Sulfate, MS Musculoskeletal MS 04 Morphine Sulfate MTX Methotrexate OXY Oxycodone, Oxycontin, Oxytocin QD Every Day, Once Daily QOD Every Other Day U Unit(s) 1. 0 mg - Trailing Zero 1 gm. 5 ml - Naked Decimal Point 0. 5 ml Inwritefield. com

Health Information Management Department 2 -3755