HIM INDEXING GUIDELINES

Transcription

1 HIM INDEXING GUIDELINES Document Scanning into PowerChart Abstract Use this document to guide you when indexing patient records. Jutting-Anderson, Paula Updated 10/29/2018

2 Indexing Guidelines Legend Note Type: Specific Test/Result Folder Preferred "Other" : i.e. Cardiology Other (Note Type) = Test ordered in system regardless of whether result referred out "Outside Record" : Test ordered & performed outside of system For all other forms Please contact HIM for Guidance Form Date Range Grouper Sub Grouper New Cerner Location/Note Type AAA Screen LAST RADIOLOGY (or IMAGING) *Site Radiology Other OR Radiology Specific Outside Record Acute Concussion Eval Care Plan CURRENT OFFICE Concussion Eval Administrative close-out forms CURRENT OTHER Administrative Closure Letter Advanced Directive LAST ADVANCE DIRECTIVE Advance Directive Document ASQ Form CURRENT OFFICE Pediactric Sreening Form Asthma Action Plan CURRENT OFFICE Asthma Action Plan Authorization to Release Information CURRENT RELEASE OF Release of Information Note (Patient) INFORMATION Billing Forms CURRENT NOT PART OF LEGAL Billing Related Bronchoscopy LAST 2 PULMONARY Bronchoscopy Cardiology - (Other than specific tests 1 YEAR CARDIOLOGY PROCEDURE Specific Test Name or "Cardio below) Test or Study" Chlamydia Screen LAST LABORATORY, PATHOLOGY *SITE Laboratory Report (Also need Pathology Report) Coding Summary/Attestations CURRENT OTHER Coding Summary Coding/Physician Queries CURRENT OTHER Coding Query Colonoscopy LAST 2 GASTROENTEROLOGY Colonoscopy Page 1 of 4

3 Colorectal Screening LAST GASTROENTEROLOGY Colonoscopy Consent to Treat CURRENT CONSENTS Consent Forms Consultation (Non-EMHS) LAST 3 OUTSIDE PATIENT RECORD Consultation Report Death Record CURRENT DEATH Record of Death DEXA Scan LAST RADIOLOGY (or IMAGING) *SITE Bone Density Diabetic Eye Exam LAST OFFICE Ophthalmology Office Note Disability Forms LAST OTHER Disability Forms Discharge Summary (Non-EMHS) LAST 3 DISCHARGE DOCUMENTATION DISCHARGE Discharge Summary Echocardiograms 2 YEARS CARDIOLOGY PROCEDURE "Specific Test Name" or Echo Report EKG 1 YEAR CARDIOLOGY PROCEDURE Electrocardiogram EKG Emera Forms CURRENT NOT PART OF LEGAL Other, Admin - Not Released Emergency Room Notes (Non-EMHS) LAST 3 EMERGENCY DEPT ED Notes DOCUMENTATION Fetal Monitor Strips CURRENT WOMEN'S HEALTH Fetal Monitor Strips Flu Shots CURRENT MEDICATIONS AND INJECTIONS Immunization Records Gastro Procedures - Other LAST 2 GASTROENTEROLOGY Gastroenterology Procedure Genetic Tests ALL LABORATORY, PATHOLOGY *SITE Genetics Report Guardianship LAST ADVANCE DIRECTIVE Guardianship H&P s (Non-EMHS) LAST 3 ADMISSION HISTORY AND PHYSICAL Admission History and Physical Note Health Habits Questionnaire CURRENT OFFICE Pediactric Sreening Form Holters CURRENT CARDIOLOGY PROCEDURE Holter Monitor Page 2 of 4

4 Home Blood Pressure Readings CURRENT NURSING ASSESSMENT Patient Home Readings DOCUMENTATION Home Care Documents CURRENT OFFICE Home Health Summary Note Home Care Orders CURRENT PHYSICIAN ORDERS Home Health Orders Immunization records ALL MEDICATIONS AND INJECTIONS Immunization Records Impact Clinical Report (concussion) CURRENT OFFICE Concussion Eval Implant Records ALL DEVICE IMPLANT RECORDS Implant Record Insurance Cards CURRENT NOT PART OF LEGAL Other, Admin - Not Released Labs 1 YEAR LABORATORY, PATHOLOGY *SITE Legal Documents (Other than Adv LAST BY Dir/Guardianship) TYPE Mammograms LAST 3 RADIOLOGY (or IMAGING) *SITE NOT PART OF LEGAL Laboratory Report Court Documents Mammography MCHAT Form CURRENT OFFICE Pediactric Sreening Form Medical Record Requests/Admin Forms CURRENT OTHER Medical Record Administration Medicare Message CURRENT OTHER Important Message Medicare Medication list CURRENT MEDICATIONS AND INJECTIONS Medication or Injection Note Medication Prior Authorizations CURRENT NOT PART OF LEGAL Other, Admin - Not Released Occupational Therapy Notes 2 YEARS REHABILITATION OCCUPATIONAL Outpatient OT Plan Note THERAPY Office visit note LAST 3 OFFICE Specific Note Type or "Office Note Unspecified" Operative Reports ALL OPERATIVE REPORTS Operative Note Other Administrative Documents, Legal CURRENT OTHER Other, Admin - Released Medical Record Paps LAST 3 LABORATORY, PATHOLOGY *SITE Pap Smear Report Pathology Reports ALL LABORATORY, PATHOLOGY *SITE Pathology Report Page 3 of 4

5 Patient Questionnaires CURRENT HEALTHLIFE QUESTIONNAIRES Patient Submitted Questionnaires Photos 1 YEAR OTHER Photo, Clinical Physical Therapy Notes 2 YEARS REHABILITATION PHYSICAL THERAPY Outpatient PT Plan Note POA/Living Will LAST ADVANCE DIRECTIVE Advance Directive Document Prior Authorization Forms CURRENT NOT PART OF LEGAL Other, Admin - Not Released Procedure Notes ALL OTHER Procedure Note PT/INR Flowsheet LAST 3 LABORATORY, PATHOLOGY *SITE Laboratory Report Pulmonary Function Test LAST 2 PULMONARY Outside Pulmonary Function Test Radiology 1 YEAR RADIOLOGY (or IMAGING) *SITE Radiology Other OR Radiology Outside Record Referrals CURRENT REFERRAL Referral Documentation Rehab Notes LAST 2 REHABILITATION REHAB Rehabilitation Note Release of Information Patient CURRENT RELEASE OF ROI Restrictions Restrictions INFORMATION Return to Work, Return to School Forms CURRENT OTHER Return to Work/School RX Prescription Pick Up Form CURRENT NOT PART OF LEGAL Other, Admin - Not Released Sleep Study LAST 2 PULMONARY Sleep Study Speech Rehab Notes LAST 2 REHABILITATION SPEECH THERAPY Outpatient Speech Language Plan Note Stress Test 1 YEAR CARDIOLOGY PROCEDURE Cardiopulmonary Stress Test Wic Nutrition Forms CURRENT NOT PART OF LEGAL Other, Admin - Not Released Workman Compensation Form CURRENT OTHER Workers Compensation M-1 Form Page 4 of 4