Presentation on theme: "A N I NTRODUCTION T O M EDICAL R ECORDS K ATE F ARR C LINICAL D ATA C OORDINATOR."— Presentation transcript:
A N I NTRODUCTION T O M EDICAL R ECORDS K ATE F ARR C LINICAL D ATA C OORDINATOR
TRAINING SESSION: P APER M EDICAL R ECORDS
P ART O NE: Packing the charts How are the charts sent? Why do we send medical records? 1 2
P ART O NE: Why do we send charts? Reasons we send charts abroad: Office supplies difficult or expensive to purchase in developing countries To ensure our Global Standards of Care through proper medical documentation To lessen the mission preparation burden on foundation To utilize Norfolk volunteers before a mission begins Remember: Medical records are LEGAL documents which describe the systematic care through every step of a patients time with us. They allow our large teams to communicate with each other & collaborate across many medical specialties. Our records serve many purposesfacilitating education, research, etc. But the number one reason for diligent paperwork is PATIENT SAFETY.
P ART O NE: Why do we send charts? Example: Patient X is allergic to penicillin. During screening, patient or parent/guardian identifies that they are allergic, and this is documented in their screening information. The patient might have an infection or illness that the pediatrician wants to treat before they receive surgery. By checking their chart, the pediatrician knows not to prescribe penicillin. The patient receives surgery, but develops an infection at the surgical site while recovering. The Post Op nurse is able to check their chart, and avoids prescribing penicillin. The patient returns a week after surgery for Post Operative evaluation with a plastic surgeon. The surgeon sees an infection, and after checking their chart, prescribes a non- penicillin antibiotic. PENICILLIN
P ART O NE: How do the charts get there? Trunks are packed to be shipped with cargo. They are made of heavy-duty impact resistant plastic, and locks are placed on each to protect the contents. Keys are sent separately with cargo.
P ART O NE: How do the charts get there? T RUNKS P ACKED & S HIPPED W ITH C ARGO Typically for a 5 table mission, 3 trunks sent P ACKING L IST ON I NSIDE C OVER OF E ACH T RUNK Allows cargo to pass through customs more quickly Quick reference for medical records volunteers on a mission Operation Smile Incorporated 6435 Tidewater Drive Norfolk, VA TRUNK 1 45 LBS NEPAL I NCLUDES: OSI address Trunk # Weight Country E ACH T RUNK H AS C OLOR L ABEL
Packing list inside trunk lid Charts stacked inside TRUNK # 1 First 100 patient charts, additional medical records forms, labels, office supplies, ID bracelets, camera & printer supplies TRUNK # 2 Patient charts above 100 TRUNK # 3 Operative data forms, discharge booklets, Pre- Op labels, printer paper P ART O NE: How do the charts get there?
What do the forms look like? P ART T WO: Inside the Charts What other supplies go with the charts? What do the chart folders look like? 1 2 3
P ART T WO: What do the charts look like? W HAT C OLOR C HARTS G ET S ENT? A SIA C ENTRAL L ATIN A MERICA
P ART T WO: What do the charts look like? Charts labeled as YEAR, First Letter of CITY, CHART # May 2011 Asunción, Paraguay E XAMPLE: Chart # 045
Page 1-3: Collects basic patient background information, demographics, prenatal & medical history Page 4: Preliminary screening with surgeon, anesthesiologist & pediatrician Indicates patient priority number, possible world care patients & whether a patient is cleared for surgery Page 5 & 6: Collects dental & speech information P ART T WO: What do the forms look like? S CREENING I NFORMATION:
The minimum amount of data that must be collected for a patient to schedule for surgery: Chart Number Priority Number Cleared for Surgery Signatures P ART T WO: What do the forms look like?
P RIORITY N UMBERS: Global Standards Medical Policy 10-1: used to schedule patients on mission based on diagnosis, age, and whether they were a previous OS patient. Primary Repair of Cleft Lip - Ages 6 months and older P ART T WO: What do the forms look like? 2 1 Primary Repair of Cleft Palate - Ages 1 – 6 years Patients Returning with Surgical Complications or Dehiscence of Operation Smile Repaired Cleft Lip – All ages Patients Returning with Surgical Complications of Operation Smile Repaired Cleft Palate – All ages 3 Primary Repair of Cleft Palates - Age 6 to Adult
P RIORITY N UMBERS: Global Standards Medical Policy 10-1: used to schedule patients on mission based on diagnosis, age, and whether they were a previous OS patient. Secondary Repairs of Lips and Palates - All ages P ART T WO: What do the forms look like? 5 4 Other Conditions – All ages Not a Candidate: Patients condition does not fall within any of the above categories treated by Operation Smile & is not a candidate for this mission, future missions, or World Care NC Potential World Care Candidate -Candidates for surgery whose condition is too complex to be treated during an Operation Smile Mission or are unable to receive surgery due to mission time or resource constraints. WC
Is needed for EVERY prospective patient DOES NOT guarantee the patient will receive surgery Three Part Form: 1. Screening Consent 2. Medical consent - Procedures - Blood transfusion - Tissue samples - Risks 3. Optional Clauses - Research consent - Observer - Media Refusal DOES NOT mean surgical candidate is excluded P ART T WO: What do the forms look like? C ONSENT:
D IAGNOSIS & P ROPOSED P ROCEDURE: If the patient does not have a cleft lip, palate or nose, NORMAL must be checked for complete diagnosis Must be filled out COMPLETELY by the surgeon Procedure Proposals indicated only for THIS mission. If patient diagnosis not listed on any section, have surgeon use OTHER P ART T WO: What do the forms look like?
O PERATIVE DATA: Lip & Nose: Pages 1-5 Palate & Fistula: Page 6 Other: Page 7 Anesthesia fills out top part of section for surgery Three Parts: Remember to get signatures for each section3 sections, 3 signatures P ART T WO: What do the forms look like?
A DDITIONAL F ORMS: Recovery Post Op Nursing Flow Sheets Medication Administration Discharge Orders Anesthesia Pre & Post Op Orders Variance Note WHO Surgical Safety Checklist P ART T WO: What do the forms look like?
S CREENING C HART: Speech Dental Diagnosis 1-3 Screening pg 4 Consent Screening pg 1-3 P ART T WO: What do the charts look like? Screening pg 4 on top right side to easily reference during surgical scheduling
O PERATIVE C HART: 1. Move all screening data to left side 2. Place Operative Data forms in order of mission Surgery = top Discharge = bottom 3. Place WHO Surgical Safety Checklist on top of left side P ART T WO: What do the charts look like?
O PERATIVE C HART: WHO Surgical Safety Screening Pages 1-4 Diagnosis Pages 1-3 Dental Speech Consent Variance Note Discharge Evaluation Post Op Orders Pre Op Orders Medication Administration Post Op Nursing Flow Sheets Recovery Form Anesthesia Operative Data Pages 1-7 P ART T WO: What do the charts look like?
PICU C ODE S HEET Form that is generated by the EMR volunteer Calculates precise medication dosages for patient, based on weight & age Is placed in the chart, typically on left side behind all other forms P ART T WO: What do the charts look like?
PICU C ODE S HEET P ART T WO: What do the charts look like? C h a r t #, N a m e A g e, W e i g h t
S TICKERS: Screening sticker, write patient chart number to ensure identification if separated from chart, goes on patient Allergy sticker, which goes on front of charts of patients with allergies No Photo/Media sticker, goes on the patient, indicated they refused consent for photos and/or video recording P ART T WO: What do the charts look like? 045 ALBUTEROL RETURN PREVIOUS CHART # PATIENT NAME MISSION SITE Return Sticker: For previous Operation Smile patients. Previous OS chart # and patient name are written on the sticker.
Priority stickers: filled out after screening, indicates information for surgical scheduling, later put on Clinical Coordinator schedule board Pre-Op assessment sticker: go on front of each chart for patients receiving surgery only Christine Anderson, CC P ART T WO: What do the charts look like?
C OMPLETE C HART Pay attention to writing on front of chart! It often contains important info such as cancellations, etc. P ART T WO: What do the charts look like?
P ATIENT ID B RACELETS 2. Write their name in the center of the bracelet PATIENT NAME Age Hemoglobin Weight PriorityChart # 3. Write the age, hemoglobin, and weight at the bottom 1.Write each patients chart number and priority number at the top of the ID bracelet P ART T WO: What other supplies are sent?
A LLERGY ID B RACELETS The allergy bracelet is placed on patients who are allergic to medication or medical materials they will encounter in the hospital, such as latex. The specific allergy should be clearly written on the bracelet. P ART T WO: What other supplies are sent?
O FFICE S UPPLIES P ART T WO: What other supplies are sent? A seemingly small detail, but VERY important to get the medical records tasks completed.
THREE: Importance of Data Collection EXAMPLE: A surgeon does not fill in the procedure & technique on the chart. 1 The EMR is unable to electronically enter the procedure into the database. The MOC report cannot be accurately completed with mission statistics. ??? Post Operative evaluations cannot be properly completed without surgery. Other specialties are unable to provide proper care & discharge orders
THREE: Importance of Data Collection …a word on signatures: A signature on a surgical form means that surgeon takes legal and medical responsibility for that patients care. This signature MUST be of a credentialed, board certified surgeon. We CANNOT accept signatures of residents, observers, or non-credentialed surgeons.
FOUR: P APER M EDICAL R ECORDS T RAINING What are the responsibilities PMR volunteers? What do PMRs do during screening? What do PMRs do during surgery week? 1 2 3
FOUR: P APER V OLUNTEER R ESPONSIBILITIES Collect printed name and signatures from all team members. A T THE F IRST T EAM M EETING: Katherine Farr PRINT SIGN Ensure that every medical team member has SIGNED and PRINTED their name. This is important as this sheet is used to link a signature on the chart with the identity of the team member whose signature it is.
A T THE F IRST T EAM M EETING: Introduce yourself to the team so they will be familiar with you & your role. This will help later when you may need to get complete signatures. Answer any questions about the forms. If you are unsure, ask the mission coordinator or team leaders. FOUR: P APER V OLUNTEER R ESPONSIBILITIES
Make sure that translators have been arranged to assist during screening, introduce yourself to them. A T THE F IRST T EAM M EETING: Instruct the translators to write answers down on forms in English (or, in Latin characters) as well as native language. Instruct the medical records volunteers to complete each form in legible handwriting in ALL CAPS so each specialty can read them. FOUR: P APER V OLUNTEER R ESPONSIBILITIES IMPORTANT
a note on handwriting: FOUR: P APER V OLUNTEER R ESPONSIBILITIES IMPORTANT Handwriting differs from country to country. It is always best to try to see how the translators are completing forms at the beginning to correct any confusion. Try to write in ALL CAPITAL LETTERS. This is not only important for proper spelling of patient names, addresses, etc, but is a patient safety issue, particularly with numbers. Good numbers: Trickiest number: 71 with a hat, 4 with a triangle, 9 with a small loop, etc.
S CREENING: FOUR: P APER V OLUNTEER R ESPONSIBILITIES Potential patients are screened for approximately two days at the beginning of a mission, either indoors or outdoors. Screening is organized into different stations – medical records should be station #1 SCREENING STATION Make sure the coordinators obtain the keys & unlock the trunks before screening starts.
S CREENING: FOUR: P APER V OLUNTEER R ESPONSIBILITIES The setup of the medical records stations should be such that there is room for translators, med recs staff, and the patients/parents/guardians.
S CREENING: Patients will arrive for the first day of screening, and screening will start when the coordinators see that everyone is ready Patients will be escorted to station 1 by team members or volunteers, and will go over the forms with translators and medical records volunteers. FOUR: P APER V OLUNTEER R ESPONSIBILITIES
S CREENING: Each patient is assigned a chart number in numerical order, starting with patient 001. A screening sticker with the chart number written on it is placed on the patient, in the event that they are separated from their chart. 045 FOUR: P APER V OLUNTEER R ESPONSIBILITIES
S CREENING: Screening 1Screening 2Screening 3Screening 4 Consent Diagnosis 1Diagnosis 2 Diagnosis 3Dental Speech 1. Complete personal info, demographics, prenatal, medical history, chart number, site & date on Screening pgs Fill in name, chart number, site & date on Screening pg 4 3. Complete consent form 4. Fill in name, chart number, site & date on Diagnosis pgs 1-3, dental & speech forms 5. Enter patient into Log Sheet 6. Give patient OpSmile sticker 7. Send chart & patient to station 2 Write chart # on sticker 011 FOUR: P APER V OLUNTEER R ESPONSIBILITIES
S CREENING ID P HOTO: Photo is of patients face for identification purposes only, NOT a technical photo, as with PIT photos. Chart ID photo PIT photo Shows face, adequate for recognition Follows strict technical parameters for precision FOUR: P APER V OLUNTEER R ESPONSIBILITIES
S CREENING ID P HOTO: Bad photo Better photo Cant see entire face of patient, necessary for identification and surgeons use Can see whole face, still has chart number visible FOUR: P APER V OLUNTEER R ESPONSIBILITIES
S CREENING ID P HOTO: 1. Print photo, then write OpSmile chart number and write patients name on back of photo Chart # 011 John Smith 2. Staple photo on LEFT side of patient folder with smooth side of staple on outside of folder *Only ONE ID photo per patient; unfortunately we cannot give extra photos to patients or family 3. Remind patient/parent NOT to leave with chart, send them to the next station (PIT) 4. Inform patient/parent when & where surgery schedule will be posted [ FOUR: P APER V OLUNTEER R ESPONSIBILITIES
Organize charts in order of PRIORITY for the team leader surgery schedule meeting Attend the surgery schedule meeting (at least the Lead Medical Records Volunteer) At this meeting, team leaders will use the Patient Priorities to come up with the schedule for each day: FOUR: P APER V OLUNTEER R ESPONSIBILITIES A FTER S CREENING:
Organize the charts by day, table, and order. Give the Dental Patient Log to the dentist. This is so they may document patients they see in the dental clinic, which runs during surgery week. FOUR: P APER V OLUNTEER R ESPONSIBILITIES A FTER S CREENING: MONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAY
Separate the original copies and carbon copies for non surgical patients. Staple the yellow carbon copies together for each chart and leave them in-country. Re-stuff the white original copies into the folders and file them in the trunks in numerical order. FOUR: P APER V OLUNTEER R ESPONSIBILITIES A FTER S CREENING: Get surgery schedule from EMR volunteer. Give this to Team Leaders for following day of surgery. After each screening day, tally the number of patients, priorities, age groups, and gender, and compare these numbers with the EMR volunteer. Reconcile any discrepancies.
For surgical patients, move screening forms to the left side of the chart, collate & add operative forms to right side, & add the WHO Surgical Safety Checklist to the top of the left side. Do this the day before each surgery. FOUR: P APER V OLUNTEER R ESPONSIBILITIES A FTER S CREENING: Complete the patient info at the top of each Operative form. Put the pre-operative assessment sticker on the outside of the charts. Complete ID bracelets for following day of surgery Give the following days charts to the Pre/Post Nurse. REMINDER: The surgery schedule is constantly changing. Work ahead as much as you can, but prioritize readying the following days charts first. Give Discharge Booklets to the Pre/Post Nurse to give to patients. Obtain PICU Code Sheets from EMR, place in charts
ALL SCREENING CHARTS RETURNED FOUR: P APER V OLUNTEER R ESPONSIBILITIES P RE S URGERY W EEK C HECKLIST: LEFT HALF OF PATIENT LOG COMPLETE (CHART NUMBER, NAME, TELEPHONE, AGE, SEX) MONDAY SURGERY CHARTS READY (FORMS COLLATED & FILLED IN, PRE OP STICKER, ID BRACELET, PICU SHEET) MONDAY SURGERY SCHEDULE CONFIRMED SCREENING NUMBERS RECONCILED WITH EMR: TOTAL NUMBER SCREENED TOTAL MALE / FEMALE PRIORITY NUMBERS AGE GROUPS
C OMPLETE S URGERY S CHEDULE F ORM FOR E ACH DAY: Fill in the date, surgery day, & mission site Complete columns for each table, listing the patients chart number, name, sex, age, procedures performed, weight, lab information, & dental. Note the total # of surgeries & total # of procedures on the tally, and reconcile the numbers with EMR daily. *Complete a page for each surgery day FOUR: P APER V OLUNTEER R ESPONSIBILITIES D URING S URGERY W EEK:
For surgical patients, continue to move screening sheets to the left side of the chart and add the WHO Surgical Safety Checklist to the top of the left side. Continue to collate and stuff operative packets on the right side of the chart. Track the going in and coming out of surgery on the surgery schedule. Ensure that charts are stored in a secured, safe location each night, preferably a locked room with limited access. D URING S URGERY W EEK: FOUR: P APER V OLUNTEER R ESPONSIBILITIES Collect the discharged patients charts from the Pre/Post Nurse starting the second morning of surgery. Record any changes to surgical procedures (from the discharged patients charts) on the Surgery Schedule print out. Fill out the second half of the Medical Patient Log from the patients charts directly. Confirm surgery schedule for next day with Clinical Coordinator each night.
Separate the original copies and the carbon copies for all patients. Staple the yellow copies and leave them in-country. Re-stuff the original copies in the same order that they appear before they were separated and place them in the trunks, numerically. Fill out the Statistics Tally Sheet from the Medical Patient Log. Leave the Post Op Evaluation forms in country for use during One Week Post-Op. RECONCILE ANY DISCREPENCIES BETWEEN EMR & PAPER TALLY BEFORE THE MISSION ENDS. A FTER S URGERY: FOUR: P APER V OLUNTEER R ESPONSIBILITIES IMPORTANT
After every chart for the previous day of surgery returns, document the number of procedures on the Tally Sheet: A FTER S URGERY: FOUR: P APER V OLUNTEER R ESPONSIBILITIES IMPORTANT III Feb 1, 2012 II Tally the days totals, and reconcile numbers with EMR daily. Do NOT wait until the last day to make sure numbers are matching!
During the week of surgery, patients will continue to come to the hospital to be screened. Ask the team leaders and clinical coordinator how they want this part of screening to work. Pull next unused chart in numerical order as you screen patients. Complete the screening forms. Make sure that a PIT photo is taken. Arrange for all the specialties to see the patient. The patient will be placed on the surgery schedule at the team leaders discretion. FOUR: P APER V OLUNTEER R ESPONSIBILITIES D URING S URGERY WEEK: If the patient is selected for surgery, let the patient know when to return, if applicable. Should the patient not be selected they will be notified at the time of screening. If patients show up on the last day of surgery, collect information and provide it to the local in-country Operation Smile Manager.
ALL SURGERY CHARTS RETURNED, COMPLETED & IN TRUNKS FOUR: P APER V OLUNTEER R ESPONSIBILITIES P OST S URGERY W EEK C HECKLIST: RIGHT HALF OF PATIENT LOG COMPLETE (DENTAL, PROCEDURE, PRIORITY, SURGERY DATE, SURGEON) YELLOW COPIES OF FORMS SEPARATED & STAPLED FOR FOUNDATION TALLY SHEET COMPLETED SURGERY NUMBERS RECONCILED WITH EMR: TOTAL NUMBER SURGERIES TOTAL MALE / FEMALE PRIORITY NUMBERS AGE GROUPS PROCEDURES PERFORMED DENTAL LOGS RECEIVED
TRAINING SESSION: E LECTRONIC M EDICAL R ECORDS