Tag Archives: Medical Records

How to sign off on another physicians orders

Works with Paragon version 12.x

Did you know that a provider can sign off on another physicians verbal orders? This can be useful to sign off on verbal admit orders entered under another provider.

  1. Open a specific patient chart.
  2. Go to the “More” drop down on the tab list.
  3. Load the list of unsigned orders for all providers on that patient. It may take a few moments.
  4. Check the boxes for orders that need to be signed or click the check mark at the top to check all the orders. 
  5. All the orders will be checked. 
  6. Go to the bottom of the list to click to “sign-off” button.
  7. The unsigned orders will now be signed.

How to document in the correct encounter using Paragon 13.x

Documenting using physdocs on the wrong patient encounter will result in inaccurate documentation. Please make sure you document in the correct encounter.

Find the patient

Find your patient using the earch function in the upper right hand corner

Include all patients in the search

If the patient is discharged then make sure the “include active only” is unchecked.

Look for additional encounters

If your patient has additional encounters they will show up as “additional visits” in the lower right hand corner of the card.

Open list of encounters

Clicking on the “additional encounters” link will open all the additional encounters for that patient. Individual encounters can be opened by clicking on the patient name in the encounter.

REMINDER: Discontinuation of Faxing Transcribed Reports

Effective April 1, 2016 at 7:00AM, the Health Information Management Department will no longer routinely fax all transcribed dictated documents to physician offices. Lab and Radiology results will still be faxed to your office. All transcribed reports are available for your office staff on the physician portal.

Click here for instruction on remote login.

Your office staff can be assigned their own read-only access. Please contact Michael or Sue at 815-759-4330 for more information.

Signing off on deficiencies in MPF

Signing dictations

Dictated reports must be verified and signed off by the practitioner. These are instructions to sign off these reports.

Deficiencies tab

Click on the deficiencies tab to bring up the list of deficiencies. Instructions for remote login are found here.

Deficiency list

This view has a list of the current deficiencies and their status.

  1. Click on an unsigned document to activate the list
  2. Click on "process" to start the signoff process

Authentication box

User will be presented with a box to enter your PIN number. It is your physician ID number. Then click "Ok"

Sign each page

  1. Each unsigned document will be opened.
  2. Review the document and make edits where needed.
  3. Make sure to correct any blanks
  4. Scroll to the bottom of the page to activate the "complete" button.
  5. Clicking the complete button will advance to the next unsigned document.
  6. User will be taken to the main screen when all the documents are signed.

HIM NEW HOURS

HIM will begin new hours starting July 6, 2015

Internal Customers & Continuity of Care Requests:

  • M-F: 6:30am-5:30pm
  • Saturday: 7:00am-3:30pm
  • Sunday: 8:00am-4:30pm

Patients

  • M-F: 8:00am-4:30pm

Clinical Documentation Tips: CHF

In order to ensure capture of current diagnoses they must be documented within the progress notes AND the discharge summary. Diagnoses pertinent to the current visit must be documented in progress notes and carried through to the discharge summary. Including all diagnoses preceded by the words “ possible, probable, resolved, resolving, suspected, improved, improving, likely”.

Chf tip

For a printer friendly version please click here.

Medical Records (HIM) Relocation

Beginning 1/19/15, HIM at both Woodstock and McHenry Hospitals will be relocating to South Street:
First Floor (Behind double doors/main desk)
527 W. South St
Woodstock, IL 60098

With that being said, there will be no Medical Record Services at either campus. Records will be transported to the new location for scanning/completion. Patients requesting medical records will need to present at South Street for copies of their Medical Record.

Phone numbers along with other information will be released shortly.

For any questions or concerns, please contact Sarah Sipunu.

Sarah Sipunu, RHIA
Director, Health Information Managment
Centegra Health System
(815)759-4058
ssipunu@centegra.com

HPF Downtime

HPF will be DOWN from:

 

Sunday, November 2, 4:00pm

to

Monday, November 3, 7:00am

(15 Hours)

Purpose: Horizon Patient Folder (HPF) is being upgraded to McKesson Patient Folder (MPF).

Transcribed History and Physicals, Progress Notes and Consults will be auto-printed on nursing units through the weekend for availability during the MPF upgrade downtime.

For information about MPF click here.

Routine Printing Discontinued

Effective immediately, routine printing of the following transcribed documents will be discontinued:

  • H&P’s
  • Consults
  • Progress Notes
  • Operative Reports
  • PFT
  • ECG
  • EMG
  • Sleep Study
  • Stress Test
  • Cardiac Cath
  • EEG
  • TEE

In lieu of printing the above documents, please refer to HPF. For questions regarding accessing HPF and viewing documents, please contact Michael Millare or Prapti Desai at (815)759-4330.

For a printable copy of this memo click here.