a n i ntroduction t o m edical r ecords k ate f arr c linical d ata c oordinator

AN INTRODUCTION TO

MEDICAL RECORDS

KATE FARRCLINICAL DATA COORDINATOR

TRAINING

SESSION:

PAPER MEDICAL RECORDS

PART ONE: Packing the charts

How are the charts sent?

Why do we send medical records?

1

2

PART ONE: 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 beginsRemember: Medical records are LEGAL documents which describe the systematic care through every step of a patient’s time with us. They allow our large teams to communicate with each other & collaborate across many medical specialties.Our records serve many purposes—facilitating education, research, etc. But the number one reason for diligent paperwork is PATIENT SAFETY.

PART ONE: 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

PART ONE: 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.


TRUNKS PACKED & SHIPPED WITH CARGOTypically for a 5 table mission, 3 trunks sent

PACKING LIST ON INSIDE COVER OF EACH TRUNKAllows cargo to pass through customs more

quicklyQuick reference for medical records volunteers on a mission

Operation SmileIncorporated

6435 Tidewater DriveNorfolk, VA 23509

TRUNK 1 45 LBS

NEPAL

INCLUDES: ● OSI address ● Trunk # ● Weight ● Country

EACH TRUNK HAS COLOR LABEL

Packing list inside trunk lid

Charts stacked inside

TR

UN

K

# 1 First 100 patient

charts, additional medical records forms, labels,

office supplies, ID bracelets, camera & printer supplies

TR

UN

K

# 2

Patient charts above 100 T

RU

NK

#

3 Operative data forms, discharge booklets, Pre-Op

labels, printer paper


What do the forms look

like?

PART TWO: Inside the Charts

What other supplies go with

the charts?

What do the chart folders look like? 12

3

PART TWO: What do the charts look like?

WHAT COLOR CHARTS GET SENT?

ASIACENTRA

LLATIN

AMERICA


Charts labeled as YEAR, First Letter of CITY, CHART #

May 2011Asunción, Paraguay

EXAMPLE:

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

PART TWO: What do the forms look like?

SCREENING INFORMATION:

The minimum amount of data that must be

collected for a patient to schedule for surgery:

Chart NumberPriorit

y Numb

erCleared

for Surgery

Signatures


2 13

4

PRIORITY NUMBERS:

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


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

PRIORITY NUMBERS:

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


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Other Conditions – All ages

Not a Candidate: Patient’s 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


CONSENT:

DIAGNOSIS & PROPOSED PROCEDURE:

● 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”


OPERATIVE DATA:

Lip & Nose: Pages 1-5Palate & Fistula: Page 6Other: Page 7

● Anesthesia fills out top part of section for surgery

● Three Parts:

● Remember to get signatures for each section—3 sections, 3 signatures


ADDITIONAL FORMS:

● Recovery

● Post Op Nursing Flow Sheets● Medication Administration

● Discharge Orders

● Anesthesia

● Pre & Post Op Orders

● Variance Note

● WHO Surgical Safety Checklist


SCREENING CHART:

Speech

DentalDiagnosis 1-3Screening pg 4

Consent

Screening pg 1-3


Screening pg 4 on top right

side to easily reference

during surgical scheduling

OPERATIVE CHART:

1. Move all screeningdata 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


OPERATIVE CHART:

WHO Surgical Safety

Screening Pages 1-4

Diagnosis Pages 1-3

DentalSpeech

ConsentVariance Note

Discharge Evaluation

Post Op OrdersPre Op Orders

Medication Administration

Post Op Nursing Flow Sheets

Recovery Form

Anesthesia

Operative Data Pages 1-7


PICU CODE SHEET

● 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


PICU CODE SHEET


Chart #, NameAge, Weight

STICKERS:Screening sticker, write patient chart number to ensure identification if separated from chart, goes on patientAllergy sticker, which goes on front of chartsof patients with allergiesNo Photo/Media sticker, goes on the patient, indicated they refused consent for photos and/or video recording


045

ALBUTEROL

RETURNPREVIOUS

CHART #PATIENT NAMEMISSION 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 boardPre-Op assessment sticker: go on front of each chart for patients receiving surgery only

Christine Anderson, CC


COMPLETE CHART

Pay attention to writingon front of chart! It oftencontains important infosuch as cancellations, etc.


PATIENT ID BRACELETS

2. Write their name in the center of the bracelet

PATIENT NAMEAge Hemoglobin Weight

PriorityChart #

3. Write the age, hemoglobin, and weight at the bottom

1. Write each patient’s chart number and priority number at the top of the ID bracelet

PART TWO: What other supplies are sent?

ALLERGY ID BRACELETSThe 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.


OFFICE

SUPPLIES


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.

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45

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 patient’s care.This signature MUST be of a credentialed, board certified surgeon. We CANNOT accept signatures of residents, observers, or non-credentialed surgeons.

FOUR: PAPER MEDICAL RECORDS TRAINING

What are the responsibilities PMR volunteers?

What do PMRs do during screening?

What do PMRs do during surgery week?

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FOUR: PAPER VOLUNTEER RESPONSIBILITIES

Collect printed name and signatures from all team members.

AT THE FIRST TEAM MEETING:

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.


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.


Make sure that translators have been arranged to assist during screening, introduce yourself to them.


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.


IMPORTANT

a note on handwriting:


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: 7—1 with a hat, 4 with a triangle, 9 with a small loop, etc.

SCREENING:


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.

SCREENING:


The setup of the medical records stations should be such that there is room for translators, med recs staff, and the patients/parents/guardians.

SCREENING:

● 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.


SCREENING:

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


SCREENING:

Screening 1 Screening 2 Screening 3 Screening 4 Consent

Diagnosis 1 Diagnosis 2 Diagnosis 3 Dental Speech

1. Complete personal info,demographics, prenatal, medical history, chart number, site & dateon Screening pgs 1-3

2. 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


SCREENING ID PHOTO:

Photo is of patient’s face for identification purposes only, NOT a technical photo, as with PIT photos.

Chart ID

photo →

← PIT photo

Shows face, adequate for recognition

Follows stricttechnical parameters for precision


SCREENING ID PHOTO:

Bad photo → ← Better photo

Can’t see entire face of patient, necessary for identification and surgeons’use

Can see whole face,still has chart numbervisible


SCREENING ID PHOTO:

1. Print photo, then write OpSmile chart number and write patient’s name on back of photo

Chart # 011John 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 family3. 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

[


• 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:


AFTER SCREENING:

• 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.


AFTER SCREENING:

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

• 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.


AFTER SCREENING:

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.


AFTER SCREENING:

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 day’s 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 day’s

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


PRE SURGERY WEEK CHECKLIST:

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 NUMBERSRECONCILED WITH

EMR:

TOTAL NUMBER SCREENEDTOTAL MALE / FEMALEPRIORITY NUMBERSAGE GROUPS

COMPLETE SURGERY SCHEDULEFORM FOR EACH DAY:

● Fill in the date, surgery day,& mission site

● Complete columns for eachtable, listing the patients chartnumber, 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


DURING SURGERY WEEK:

• 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.



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.

AFTER SURGERY:


IMPORTANT

After every chart for the previous day of surgery returns, document the number of procedures on the Tally Sheet:

AFTER SURGERY:


IMPORTANT

III

Feb 1, 2012

II

Tally the day’s 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 leader’s discretion.



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


POST SURGERY WEEK CHECKLIST:

RIGHT HALF OF PATIENT LOG COMPLETE (DENTAL, PROCEDURE, PRIORITY, SURGERY DATE, SURGEON)

YELLOW COPIES OF FORMS SEPARATED & STAPLED FOR FOUNDATION

TALLY SHEET COMPLETED

SURGERY NUMBERSRECONCILED WITH

EMR:

TOTAL NUMBER SURGERIESTOTAL MALE / FEMALEPRIORITY NUMBERSAGE GROUPSPROCEDURES PERFORMED

DENTAL LOGS RECEIVED

TRAINING

SESSION:

ELECTRONIC

MEDICAL RECORDS

a n i ntroduction t o m edical r ecords k ate f arr c linical d ata c oordinator

Documents

patient charts

ages p art t wo

penicillin slide

older p art t wo

surgery signatures p

p aper

p acking

merica slide