Dear
Physician:
As part of our desire to
improve patient care we expect that all patient care documentation will occur
in a timely manner. Documentation is a basic part of communicating
between providers and is important in documenting the care we provide to our
patients. A national patient safety goal is aimed at documenting as soon
as possible to improve the quality and timing of the note.
For
those of you who use the dictation system we have seen a large number of documents
that are dictated well after care is provided.
An additional significant delay occurs in reviewing and signing those
dictations. Unsigned dictations using the electronic signature
system, Esig routinely exceed 1000 records on
any given day, and many thousands of unsigned verbal orders remain as
well.
Unsigned
dictations are not considered finalized for patient care, legal documentation,
billing or compliance/regulatory reasons.
Both
the Medical Executive Committee and the Medical Informatics/Records Committee
have approved the following MINIMUM standards for record completion, to
be implemented immediately
Operative Reports: To be dictated within
24 hours/same day of surgery (old standard 3 days)
Discharge Summaries: To be dictated within 7
days of discharge (old standard 10 days).
Signing of Esig
documents: To be signed within 2 weeks
Verbal Orders Co-sign: Current policy
requires these to be signed within 24 hours.
Please
make every effort to comply with these standards to avoid sanctions and loss of
privileges, as well as to provide excellent patient care
Thank you
for attention to this matter.
Rich
Molteni, MD
Medical
Director