Completing Records

E-mail messages are sent weekly to keep you abreast of any incomplete
and/or delinquent medical records. A weekly summary report of incomplete and/or delinquent
records is also provided to the Medical staff leadership.

You can view your incomplete records online. In order to do this, enter CI Clinical Information), R
(Medical Record Option) and I (Incomplete Records). House Officers and fellows who fail to fulfill
satisfactorily their record keeping responsibilities may be subject to disciplinary action.

DOCUMENTATION RESPONSIBILITY AND RULES

A. Attending of Record: The attending physician includes all Physicians, Dentists and
Oral surgeons who are the attending of record for a patient. In the case where a
patient is being seen in an allied health professionals office, e.g. PT, nutrition, this
person is the provider of record for this visit and responsible for the same
documentation requirements.
B. Record Completion Responsibility: No medical staff member is permitted to
complete a medical record on a patient unfamiliar to him/her in order to retire a
record. Records that are the responsibility of staff members who are deceased or
permanently unavailable will be declared complete for filing purpose by the Medical
Record Committee. A note indicating the incomplete status and reason for such is
filed in the record.
C. Completion of the Medical Records (as defined within each section of this medical
record documentation policy): Completion is the responsibility of the attending
physician. Housestaff/fellows/PAs/NPs/Nursing and other Allied Health providers may
make entries into the record but the attending is responsible for ensuring the record
is complete.
D. General Documentation Rules
i. Write, print or imprint the patient name and medical record number on the
back and front of every page.
ii. For electronic notes: sign/authenticate/ finalize notes using the authors
electronic signature key.
iii. For handwritten/typewritten/computer word entries: Include signature, date
and time, and pager or clinical ID# NOTE: Signature must be dated and
timed even if date and time appear at the beginning of the entry.
iv. Entries must be permanent and capable of being copied.
v. Use black or dark blue ink/ball-point... Note photocopying eliminates the
difference in ink color. Never use pencil, marker or a highlighter pen.
vi. Do not use abbreviations and symbols listed on the BWH unapproved
abbreviations list located on-line:
http://www.bwhpikenotes.org/HospitalwidePoliciesAndManuals/Administrativ
ePolicyManual/VII-1.doc
vii. The use of signature stamps is not permitted. See BWH Signature Stamp
Use Policy:
http://www.bwhpikenotes.org/HospitalwidePoliciesAndManuals/Administrativ
ePolicyManual/V-29.doc
viii. Authenticate by signing or entering electronic key, all verbal or telephone
orders within 24 hours (unless otherwise specified in a hospital policy).
E. How to Make Corrections (Amendments)
i. Paper medical record/flowsheet entry: draw a line through it, label it error
initial, date and time it and write the new entry. NEVER use whiteout or try to
obliterate an entry.
ii. Computer order entry: enter a general care order and describe the error or
discontinue the order in order entry. If the error is in a signed discharge
 order or an Auto Discharge Order, you must call the Help Desk and work with
the appropriate programming team to make the changes.
iii. Computer Note errors: LMR Note correction/changes can be made before
signature via preliminary notes. If made after a note is signed the note will
be automatically labeled as amendment with the date/time of amendment.
A note addendum may be made to add information to a note. The LMR error
note functionality includes the ability to retract a note due to incorrect patient,
incorrect date, patient cancel/no show or other. Retracted notes are kept
behind a special retracted tab within the Longitudinal Medical Record (LMR).
Note correction/changes in other systems such as BICS must be made via
an addendum once the note is signed.
F. Teaching Attending Documentation: BWH adheres to the guidelines set forth by the
Centers for Medicare and Medicaid Services (CMS) found at CMSs Internet Only
Manual (IOM); Medicare Claims Processing 100-04 Chapter 12. To meet the
documentation requirements of the Medicare Teaching Physician Rule, the physical
presence and involvement of the teaching physician during the key portion of each
service involving a resident must be clearly documented by the Teaching Attending.
Specifics can be found in the Appendix 1.

Documents Timeframe Sanction

Admission Note / Within 24 hours of admission. Must
History & be completed no more than 30 days
Physical before or within 24 hours after
admission. The report must be placed
in the patients inpatient medical record
within 24 hours after admission. An
updated medical record entry
documenting an examination and any
changes in the patients condition is
required when the report is completed
before (within 30 days) admission.
This updated examination must be
completed and documented in the
patients inpatient medical record within
24 hours of admission or prior to
surgery.
Attending of Within 24 hours of Admission. This
Record Note could be acknowledgement and co-
signature of Admit Note/H&P or a brief
assessment and plan for admission
Brief Op note Brief written operative note
immediately following surgery or
procedure and before the patient is
transferred to the next level of care.
Dictated Op Dictated and signed within 7 days of Suspension, Release of OR
Note the procedure time which is greater than
48 hours out from the time
of suspension
Progress Notes The patients physician care team must
document daily on all patients
Consultation At the time of observation.
Reports
Final Progress Immediately at the conclusion of the
note hospitalization
Newborn Started immediately following delivery
Documents Timeframe Sanction
Evaluation and completed immediately at the
Newborn conclusion of the hospitalization
Summary
Labor and Required for all deliveries except in
Delivery Record transit or < 20 weeks gestation.
(L&D Blue Completed and signed by the
Sheet) conclusion of the hospitalization
Discharge Dictated immediately at the conclusion No sanctions will be enforced
Summary of the hospitalization. at the hospital level until Fall,
(Dictated) Discharging Clinician: Delinquent if not 2010 when a new discharge
dictated within 48 hours. Must be documentation module will be
signed within 7 days post-discharge. released.
Attending of Record: Delinquent if not
dictated, reviewed and signed as final
within 14 days post discharge.
Any changes by the attending after the
resident has signed it, requires an
addendum.
Discharge Immediately at the conclusion of the
Order / Auto hospitalization
Discharge
Summary
Death Note In the event of an inpatient death, a
Dictation dictation is required. This must include a
brief HPI, hospital course and an
objective description of the events
leading up to the death (if known). A
death pronouncement including the
physical parameters observed, the time
of death and what family members were
informed can be dictated as part of this
or can be written in the chart. This
should be done within 48 hours of
death, signed by the discharging
clinician within 7 days and
reviewed/edited/signed by the Attending
of record within 14 days post-death.
Birth Certificate 10 days after delivery
Autopsies When an autopsy is performed,
provisional anatomic diagnoses are
recorded in the medical record within
48 hours, and the final report is made
part of the record within two months,
unless exceptions for special studies
are established by the medical staff.

* Do not abbreviate final diagnosis, procedures, or orders.

* Use only BWH approved abbreviations.

* Countersign any student workup, progress note and/or orders.

* Write legibly and use only a black ball-point pen.

* Make a correction by drawing a line through the error and then signing and dating it.
* Never use liquid paper or try to obliterate the entry.

* Do not remove records from the nursing unit after a patient is

discharged; Health Information staff will pick up the record the
same day for processing. (The department is open 24 hours a day; you
have access to records any time.) Inpatient / Same Day Surgery / IVF
/ Emergency Room records are all scanned within the 24-48 hours
after discharge. All scanned documentation are viewable in BICS or
LMR.

* Bar codes are computer sensitive and should not be defaced.

Dictating Records

Any telephone may be used for dictating. Instructions are located on all patient floors, as well as
the operating room and Health Information Services. Note: Call 617-582-5209 to obtain a copy of
"The Do's of Dictating at BWH".

Computer Access

If you do not have access to these computer systems please call the helpdesk, or if you have
questions about record requests call 617 732-6060 for further information.

Medical Record Requests

Photocopies of Protected Health Information

Requests for protected health information, related to hospital

based services, should be directed to Health Information Services to
ensure that all legal requirements are met. The attached Release of
Protected Health Information Authorization form may be completed and
forwarded to Health Information Services-Correspondence Section.

For questions regarding the disclosure of protected health information

copies, please contact Health Information-Correspondence at 617-732-
7471, Monday-Friday, 9:00am to 4:00pm for assistance.

Photocopies of Protected Health Information

Requests for protected health information, related to hospital based services, should be directed
to Health Information Services to ensure that all legal requirements are met. The attached
Release of Protected Health Information Authorization form may be completed and forwarded to
Health Information Services-Correspondence Section.

For questions regarding the disclosure of protected health information copies, please contact
Health Information-Correspondence at 617-732-7471, Monday-Friday, 9:00am to 4:00pm for
assistance.