TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
0
ACCOUNT MANAGER ........................................................................................................................... 1
MANAGER ON CALL ............................................................................................................................. 2
LOGGING IN .......................................................................................................................................... 2
INET PLAYER ........................................................................................................................................ 2
LOGGING IN ....................................................................................................................................... 2
EDIT TYPIST NAME/ID ....................................................................................................................... 3
INITIAL SETUP ................................................................................................................................... 4
REQUEST MODES ............................................................................................................................. 5
REQUESTING JOBS .......................................................................................................................... 5
REQUEST JOB BY SPECIFIC CRITERIA .......................................................................................... 7
TURN OFF REQUEST MODE............................................................................................................. 7
RETURN JOB ..................................................................................................................................... 8
VIEW JOBS TO BE TRANSCRIBED .................................................................................................. 8
RETRIEVE LOCKED JOB .................................................................................................................. 9
EDIT INET jOB .................................................................................................................................. 10
VIEW TRANSCRIBED JOBS ............................................................................................................ 11
EXIT INET ......................................................................................................................................... 12
CPSI ..................................................................................................................................................... 12
TRANSCRIBE HIM REPORT ............................................................................................................ 13
CPSI DOCUMENT STATUS ............................................................................................................. 16
REPORT TYPES ............................................................................................................................... 17
TRANSCRIBING RADIOLOGY REPORT ......................................................................................... 18
ATTACHING RADIOLOGY ORDERS ............................................................................................... 21
INITIAL WORD SETUP ..................................................................................................................... 23
PRINTING REPORTS ....................................................................................................................... 25
FAXING REPORTS ........................................................................................................................... 28
HIM/MEDICAL RECORDS ................................................................................................................ 28
RADIOLOGY ..................................................................................................................................... 30
HIM SEARCH BY PATIENT LIST ..................................................................................................... 31
ABORTING REPORT ....................................................................................................................... 32
SEARCH FOR REPORTS BY PHYSICIAN ...................................................................................... 34
HIM ................................................................................................................................................... 34
RADIOLOGY ..................................................................................................................................... 35
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
1
PRODUCTION REPORTS ................................................................................................................ 36
HIM PRODUCTION REPORT ........................................................................................................... 36
RADIOLOGY PRODUCTION REPORT ............................................................................................ 38
XENDESKTOP TOOLBAR ............................................................................................................... 40
PROTOCOLS ....................................................................................................................................... 40
WORK TYPE 7 .................................................................................................................................. 40
WORK TYPE 8 .................................................................................................................................. 40
INCOMPLETE DICTATION ............................................................................................................... 40
CANCELED/NO DICTATION ............................................................................................................ 41
UNABLE TO LOCATE PATIENT ...................................................................................................... 41
CANNED TEXT/NORMALS .............................................................................................................. 41
JOB NUMBER .................................................................................................................................. 41
CARBON COPIES ............................................................................................................................ 42
ADDENDUMS ................................................................................................................................... 42
SYSTEM DOWNTIME ....................................................................................................................... 42
TECHNICAL ISSUES/UNABLE TO WORK SHIFT ........................................................................... 43
TURN AROUND TIME ...................................................................................................................... 43
HIM SPECIFIC .................................................................................................................................. 43
HIM FORMATTING ........................................................................................................................... 43
DICTATING PA ................................................................................................................................. 43
HIM BLANKS .................................................................................................................................... 43
INCORRECT REPORT TYPE/DICTATING PHYSICIAN/PATIENT CHOSEN ................................... 43
RADIOLOGY SPECIFIC ................................................................................................................... 45
MISSING RADIOLOGY ORDER ....................................................................................................... 45
DOPPLER ULTRASOUND STUDIES ............................................................................................... 45
RADIOLOGY FORMATTING ............................................................................................................ 45
RADIOLOGY BLANKS ..................................................................................................................... 46
MAMMOGRAMS ............................................................................................................................... 46
ACCOUNT MANAGER
Hannah Morris, President Phone: 770-607-0700, ext 205 Email: [email protected]
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
2
MANAGER ON CALL
?????? PLEASE EMAIL JOB NUMBER TO CINDY@SOUTHERNTRANSCRIPTION IF YOU PUT A REPORT ON HOLD UNTIL MOC IS CHOSEN.
LOGGING IN
Navigate to the following address and run this script: http://www.taylorregional.org/trustedsite.vbs to run this script to add the Citrix server as a trusted site in Internet Explorer the first time you log in.
If you do not currently use any Citrix connections, navigate to this site and install the receiver: http://receiver.citrix.com.
Choose to download the receiver for windows and agree to the license
Choose run if prompted
Navigate to the following site to access Citrix remotely: https://secureconnect.taylorregional.org. If you get a yellow bar at the top of the page (Active X warning), right click it, and choose allow add-on.
Input username and password, enter.
Once you have logged into Citrix, click Transcription.
Click on devices on the XenDesktop Tool Bar at top of screen and place check mark next to VEC Digital Accessories Corporation USB Foot pedal.
INET PLAYER
For complete INet instructions go to: http://dacsolution.com/support/manuals/iNet_3_User_Guide.pdf
LOGGING IN
Click on INet PlayerNew
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Verify that you are logging in as yourself
Click Connect
Enter Password
Connect
EDIT TYPIST NAME/ID
DAC7
View Settings
Edit the Typist Name and Typist ID
Click OK
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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INITIAL SETUP Required:
Check Enable Notification, select Exclusive.
Check PopUp Prompt
Check AutoRefresh; Frequency in minutes: 5
Check Auto Queue
Check Display Military Time
Check AutoRefresh on Dropdown selection
Check Show Total Job Minutes.
OK
Optional:
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Adjust footpedal settings to personal preference.
Check Launch Mini-player upon Play Check Always on Top
OK
REQUEST MODES
EXCLUSIVE – Retreives jobs that have been assigned exclusively to you. If a Manager On Call (MOC) assgins a job, MOC will notify transcriptionist job has been assigned and Inet toolbar wll alert transcriptionist .
CATEGORY – Routes reports FIFO by Work Types (See Category List Below)
SPECIFIC – Routes reports by physician, subject ID or job number.
FIFO – Routes all work types First In First Out. Does not take into consideration the contratural turnaround times.
REQUESTING JOBS
Route jobs using Categories in the following order:
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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o Early morning staff should clear Stats, History and Physicials, Progress notes and Consults first.
o If assigned to transcribe HIM and Radiology reports, request by Category 16. o If assigned to transcribe HIM only, request by Category 15. o If assigned to transcribe radiology only, request by Categories 4 and 10.
Before changing categories, refresh “In Queue” list in INet to ensure all work types are kept within turn around.
Radiology jobs should be completed by 4 p.m.
DO NOT CHOOSE JOBS FROM THE IN QUEUE LIST!!! THIS IS CHERRY PICKING!!!!
WORK TYPE WORK TYPE / CATAGORY
TURNAROUND TIME
STAT
7 2 hours
EEG ECHO CATH
8 4 hours
RADIOLOGY – BLECKLEY 10 4 hours
RADIOLOGY – TAYLOR 4 4 hours
EMERGENCY ROON NOTES 5 4 hours
PROGRESS NOTE 11 4 hours
CONSULTATION 3 4 hours
H&P 1 8 hours
OPERATIVE/PROCEDURE REPORTS 2 12 hours
DISCHARGE SUMMARY SHORT STAY SUMMARY
DEATH SUMMARY TRANSFER SUMMARY
6 24 hours
LETTERS 9 STS DOES NOT TRANSCRIBE
SEQUENTIAL ORDER, ALL WORKTYPES BY TURNAROUND
TIME 15 SEE ABOVE
SEQUENTIAL ORDER, HIM/MEDICAL RECORDS BY TURNAROUND TIME
16 SEE ABOVE
TAYLOR REGIONAL JOBS 21 SEE ABOVE
BLECKLEY MEMORIAL JOBS 22 SEE ABOVE
Once jobs have loaded, double click on the first available job to begin playing.
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Mini-player information is displayed as follows: Job number/doctor/work type/acct #//dictate date/dictate time
REQUEST JOB BY SPECIFIC CRITERIA
Specific
Request
Select appropriate bullet.
Input Document Number(job number), work type number , subject number, or Department
Request.
TURN OFF REQUEST MODE If currently requesting jobs, right click Request.
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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RETURN JOB
Right click, return job to queue
Click OK
VIEW JOBS TO BE TRANSCRIBED BY JOB STATUS
Status “In Queue.”
Any Typist
Any Author
Leave all other fields blank.
Click List
Number of jobs and minutes will be listed at bottom of player
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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BY FILTER
Date filters blank
Select Filter from drop down
RETRIEVE LOCKED JOB If you are disconnected while actively typing job:
Click on In trans under status
Click List.
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Double click on job to bring into play mode.
If you receive error that is it in use by you, right click, return to queue and retrieve job from In Queue.
EDIT INET JOB If the information in INet is incorrect, we must edit and enter correct information before completing or returning the job.
Click adjust.
Correct incorrect information entered.
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Continue & Update to continue transcribing job or Return and Update if job is complete in INet.
VIEW TRANSCRIBED JOBS
You will be able to view only jobs you have transcribed.
Show job filters
Completed
Enter date range
Click on list
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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EXIT INET
Return job in queue.
Go to file, disconnect
Go to file, exit
CPSI
Click on CPSI icon
Chose facility
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Note: You will need to log into 2 separate sessions, one for Taylor and one for Bleckley and switch between each, based on the dictating physician. Session: CPSI System = Taylor Session: BMH = Bleckley
Enter user name and password, connect
TRANSCRIBE HIM REPORT For complete CPSI Transcription Instructions go to: https://cphelp.cpsi.com/v19/ptmgt/him/index.html
Click on Patient Accounting
Enter Patient Account Number. *Taylor Account numbers begin with a letter and a 0 (currently letter L and will begin with L until L99999). Bleckley account numbers do not have a preceding letter and begin with a 36 currently.
Medical Records (alt+M)
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Transcription System (alt+T)
New Document (alt+N)
Enter dictating physician’s name. Note, if dictation is by PA, enter PA’s name as dictating physician.
Global (alt+G).
Chose report type. PgDn to see all report types. **Do not pick echocardiogram document type here; these must be typed as radiology.
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Once patient screen opens, enter dictated date. It must be transcribed mmddyy format with no spaces, dashes or hyphens. Enter dictated time in military time.
Click on Edit
We are to print Stat, H&P, preop H&P and consult reports. Make note of whether or not the patient is an OB patient and patient’s Room/Stay Type in report header for printer location, if report is to be printed.
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Once you have transcribed report, click on Save/Exit
The “Sending File” box opens and closes.
Focus returns to the MR Transcription Document Options screen. If report is to be printed or faxed, see below Printing and Faxing Reports If report is NOT printed, press the zero key.
Click on Final to send to draft or Hold to send to QA. We do not use Require Edit. *Note if Transcription Document Status screen does not open, click in blank gray area MR Transcription Document Options screen and press the zero key.
CPSI DOCUMENT STATUS H - Hold
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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U – Unsigned S – Signed
REPORT TYPES Click on PgDn to see all report types.
BLECKLEY
TAYLOR
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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TRANSCRIBING RADIOLOGY REPORT For complete CPSI Radiology transcription instructions go to: https://cphelp.cpsi.com/v19/clinical/rad/index.html
In HM Dept 40, click on Master Selection
Medical Records(alt+M)
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Transcribe Orders
Enter Patient Number
Radiology
Transcribe orders
Status changes to Transcribe Mode
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Highlight order to transcribe
Once order is highlighted in red, select process.
Enter physician’s initials (see physician list), continue.
Enter your initials, click continue
Report must be transcribed between \CNTO\ and \CNTx|
We are to print or fax a radiology report if it is a stat or if the radiologist dictates to flag the report or dictates to send a carbon copy. Make note of whether or not the patient is an OB patient and patient’s Room/Stay Type in report header for printer/fax location
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Save/exit
Click on Final.
If report is to be printed or faxed, see below Printing Reports and Faxing Reports
Othwerwise, press escape key or click on x to close box.
ATTACHING RADIOLOGY ORDERS When the physician dictates more than 1 report on a job or if exam is a mammogram, we will need to attach the order not used for transcription to the report:
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Once report has been transcribed and saved, click on All Orders.
Select Attach To Transcribed Order
Status will change to ATTACH MODE
Highlight the order on which there is no transcription.
Status will change to Attach.
Highlight the order on which there is transcription.
Status will change to Attach To
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Click on Process
Status for all orders will change to Unsigned.
INITIAL WORD SETUP This is a one-time set up.
Once in first report, change the below settings:
Go to File
Options
Autocorrect options
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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AutoCorrect Tab - Remove checkmarks as shown below. Click on AutoFormat As You Type tab.
In the AutoFormat As You Type tab, remove checkmarks as shown below. Click on the AutoFormat tab
In the AutoFormat tab, remove checkmarks as shown below, OK
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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PRINTING REPORTS HIM
ALWAYS PRINT THE FOLLOWING: Stat H&P Preop H&P Consult
Once you have transcribed report, click on Save/Exit
After “reading” box closes, do not type zero to exit.
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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From the MR Transcription Document Options screen, click on Print
Enter printer number in Line Printer Number field: TAYLOR
Inpatient (1), Outpatient (2), Observation (4) and Swing Bed (5) o If “Room:” field in header has CCU/ICU, print to 202 (CCU/ICU) o If “Room:” field in header is a number, print to 200 (Nurse’s Station) o If patient is an OB patient, print to 203 (L&D)
Emergency Room (3) If “Room:” field in header has ER, print to 201 (Emergency Room)
BLECKLEY Inpatient (1), Outpatient (2), Observation (4) and Swing Bed (5)
Print to 120 (Nurse’s Station) Emergency Room (3)
Print to 123 (Emergency Room)
OK
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Focus returns to the MR Transcription Document Options screen. Click anywhere in gray area, type the zero key.
Click on Final to send to draft or Hold to send to QA. We do not use Require Edit. *Note if Transcription Document Status screen does not open, click in blank gray area MR Transcription Document Options screen and press the zero key.
RADIOLOGY ALWAYS print report if:
o It is a stat dictation o The physician states to flag the report on an inpatient stay type o Dictates to flag report on an ER patient with outpatient stay type.
How to print report
If necessary, highlight exam to print
Click on Print
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Enter Printer Number, continue. TAYLOR
Inpatient , Observation, Outpatient and Swing Bed o If “Room:” field in header has CCU/ICU, print to 202 (CCU/ICU) o If “Room:” field in header is a number, print to 200 (Nurse’s Station) o If patient is an OB patient, print to 203 (L&D)
Emergency Room (3) If “Room:” field in header has ER or if patient is outpatient and admitting doctor is an ER physician, print to 201 (Emergency Room)
BLECKLEY Inpatient (1), Observation (4) and Swing Bed (5)
Print to 120 (Nurse’s Station) Emergency Room (3)
Print to 123 (Emergency Room)
FAXING REPORTS
HIM/MEDICAL RECORDS If the physician dictates to send a carbon copy, we are to fax report
Save/Exit report.
After “reading” box closes, do not type zero to exit.
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Click on Fax/Send.
Chose Admitting Physician Office if copy to go to admitting physician.
Yes.
Chose Another Physician Office if copy to go to a different physician.
Search for physician’s name or enter Physician Number – Pick Staff Physician if name on Physician list or search by Non-Staff if not.
Yes
If physician not listed and you have the fax number, you may pick Special Number Entry
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Enter Fax number
OK
CPSI returns to MR Transcription Document Options screen. To finalize/hold the report, click anywhere in blank gray on MR Transcription Document Options screen and type zero to bring up box to finalize/hold report.
Click on Final to send to draft or Hold to send to QA. We do not use Require Edit
RADIOLOGY Fax the report if:
Stat dictation on outpatient stay type.
Dictates to flag report on a non ER patient outpatient stay type.
Physician dictates to send a carbon copy.
If necessary, highlight exam to fax
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Click on Send
Enter number for faxing selection.
Once physician’s name comes up, enter.
Yes, No, 0-Abort? Y, enter
HIM SEARCH BY PATIENT LIST
Patient List (alt+p)
If searching for older visits, search by master index. LAST FIRST (all caps, no comma)
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Click on patient name if account number shows “multi” to see list of available visits. Once list opens, double click to select account to use.
ABORTING REPORT HIM
Select Abort/No Save
Yes
RADIOLOGY
Select Abort/No Save
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Yes
Hold
Delete
Type YES, continue
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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SEARCH FOR REPORTS BY PHYSICIAN
HIM
In MEDICAL RECORD/DEPT 40, select print reports
Medical Records
Build Transcription Work Files
Select Transcriptions
Pick date Range
Generate
CPSI will go back to base menu.
Print Reports
Medical Records
Dictation/Transcription by Pat/Phys
Windows View or Print
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Sort by Physician
Make note of Account Number(s) from the Dictation/Transcription PDF file to view report.
Close out PDF file.
Exit.
Follow steps to create new radiology report.
Instead of clicking on New Document in the Transcription Document Lookup box, click on report you wish to view.
Click on View
RADIOLOGY
Follow instructions for Radiology Productivity. *Refer to radiologist’s schedule to reduce date range search due to length of time CPSI takes to generate report.
Make note of account number(s) for desire physician’s reports.
Follow instructions for creating new radiology report until instructions to “click on transcribe orders.”
Click on Transcribed tab
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Click on the exam you wish to view.
Look
PRODUCTION REPORTS You will need to log into each facility to run the HIM and radiology line counts for both Taylor and Bleckley for payroll. It is recommended that you run the radiology reports daily because it takes CPSI an extremely long time to create this report, especially when a multiday range is used.
HIM PRODUCTION REPORT
Check to ensure in Dept 40
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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If not in Department 40, click on change Department.
Once Department Signon box opens, select Medical Records.
Print reports
Medical records
Navigate to page 2 and then Transcriptionist Productivity.
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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Windows View or Print
Enter date range, Print. If Print in Detail is checked, CPSI will list every report transcribed and totals per report.
All transcriptionists’ production is listed. Scroll to bottom of report and locate your initials under Recap. The number of lines is what you will submit for payroll purposes.
RADIOLOGY PRODUCTION REPORT *CPSI does not calculate the lines for radiology reports until the report has been signed. This report takes a significant amount of time to run, so it is recommended to not use a large date range.
Check to ensure in Dept 40
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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If not in Department 40, click on change Department.
Once Department Signon box opens, select Medical Records.
Print Reports
Select Transcription Log.
Windows View or Print
Enter Beginning and Ending dates.
Do not place check mark in All Dates field.
Number of Copies: 1
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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All transcriptionists’ production is listed. Scroll to bottom of report and locate your initials under Recap. The number of lines is what you will submit for payroll purposes.
XENDESKTOP TOOLBAR To access your computer while in full screen mode, click on Home. To disconnect from the Taylor Desktop at end of day, click on disconnect.
PROTOCOLS
WORK TYPE 7 Work type 7 in Inet includes all stat reports (HP, CON, OP, etc.), letters, memos, miscellaneous work types.
If work type 7 is a Stat/Priority, transcribe report as a stat.
If work type 7 is a letter, memo or other miscellaneous work type, change the work type to a 9 and return it to the queue for in-house staff to transcribe.
WORK TYPE 8
Type the following as an HIM report: o Stress Test o 24-Hour Holter
Type as Radiology report: o Echocardiogram
INCOMPLETE DICTATION
Type what is dictated.
HOLD report in CPSI
Complete the job in iNet
Send email to Connie Harrison ([email protected]) with job number and account number.
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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CANCELED/NO DICTATION
Abort report in CPSI
Update job with any missing or incorrect information.
Complete job in INet.
Email job number and subject number from INet to Connie Harrison ([email protected]).
UNABLE TO LOCATE PATIENT If unable to locate patient, account number or if unsure of dictating physician:
DO NOT mark job as complete!
Change the job WT to 9.
Return the job in iNet
Email brief description of issue and job number to Connie Harrison ([email protected]). If issue is physician and account number is available, also send account number.
CANNED TEXT/NORMALS The normals are available in Shorthand and also on the Transcription Desktop in the Office Notes folder. If you notice Shorthand is missing a normal or of there are any discrepancies in what is in SH and what is in the Office Notes folder, send information to Cindy Rudeseal ([email protected]).
JOB NUMBER
Transcribe job number on bottom of report, between last line of transcription and signature line with 1 blank line between each section. EXAMPLE: Prophylaxis. Start Protonix 40 mg p.o. daily orally and Lovenox 40 mg subcutaneously daily. Job#: 338709 DICTATED BY: ATUL DEVANI
If multiple reports are dictated on one job Add the job # to the report like normal, but add an a, b, c, etc., to the end of the job # to differentiate the different patients. Example: JOB # 123456a JOB # 123456b
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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CARBON COPIES
Type carbon copy on bottom of report between job number and Dictated By line with 1 blank line between each section. Example: Prophylaxis. Start Protonix 40 mg p.o. daily orally and Lovenox 40 mg subcutaneously daily. Job#: 111111
cc Zoe Jones, MD
DICTATED BY
FAX carbon copy. See Faxing Reports instructions.
ADDENDUMS
Do not create a separate report for an addendum.
If report is unsigned, modify document and add to report.
If report has been signed, – Create an addendum
If the report has been archived (gone to Clinical History), email Connie Harrison ([email protected]) the job number, patient account number and complete the job in iNet
SYSTEM DOWNTIME If CPSI is experiencing downtime and the facility has requested we follow the system downtime procedure:
Transcribe report in a blank word file.
Transcribe patient name and subject ID, if available, at top of report.
Add dictated by, dictated date/time and your initials to bottom of report, below job number. DICTATED BY: Zoe Jones, MD DICTATED D/T: 02/13/2015 1212 hours TRANSCRIPTIONIST: CR
Save report as LAST – FIRST – ACCOUNT NUMBER – YOUR INITIALS (DOE – JOHN- L00000 - CR) in the System Down Time folder. This folder is located in the office notes folder on the Transcription desktop:
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
43
TECHNICAL ISSUES/UNABLE TO WORK SHIFT If you are unable to connect to Taylor or are unable to work due to other technical issues or emergency/illness, please call the office and email all transcriptionists on the Taylor account and all office personnel.
TURN AROUND TIME If jobs are out of turn around, if volume of work is high and there is no MOC scheduled, email transcription and office staff with number of reports and minutes to request additional help.
HIM SPECIFIC
HIM FORMATTING
Remove headers in report templates that are not dictated.
Transcribe date of admission, discharge, consult, etc. on report, if dictated.
Always number diagnosis/impression, even if not dictated to do so.
DICTATING PA
Select PA as dictating physician in CPSI.
No note denoting supervising physician on report is necessary. Once PA signs report in CPSI, it will go to supervising physician’s queue for that provider to sign report.
HIM BLANKS Type (5) underscore lines to leave a blank.
One to Two blanks o Draft report in CPSI. o Complete job in INet
More than two blanks o Add time stamp from iNet next to blank.
Example: The patient was admitted to _____(0:12) for CHF.
o Place report on hold in CPSI. o Mark job complete in INet.
INCORRECT REPORT TYPE/DICTATING PHYSICIAN/PATIENT CHOSEN If any discrepancy between the report type dictated and what is entered in INet, if unsure of report type for any reason, if wrong report type is chosen, if incorrect patient chosen or if unsure if correct physician or if picked wrong physician, do the following. For issues that require clarification from the facility, for example discrepancy or unsure of report type, verification of dictating physician, etc.
Do not transcribe report.
Change the Inet work type to a 9.
Send email with job number and account number to Connie Harrison ([email protected]) with brief description of issue.
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
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If issue can be resolved by transcriptionist:
EXAMPLES: Provider dictates discharge summary at beginning but later states is a transfer summary and patient is being transferred to another facility. Accidentally picked the incorrect physician or patient. OP Note document type chosen when should be a Procedure Note.
Do Not save report.
If anything has been transcribed, copy text and paste into a blank Word file. o Abort/No Save report in CPSI
o Back arrow or escape key. o This will take you back to the screen where Transcribe Orders is located.
o If patient is correct, follow transcribing report instructions from this point.
o If patient is incorrect, back out to Hospital Base Menu screen to locate correct patient. o Once new report is open, copy and paste what was transcribed into new report and complete
report as usual.
If report has already been saved and the status is unsigned in CPSI, edit report and put on hold. Send email with job number and account number to Connie Harrison ([email protected]) with brief description of issue.
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
45
If report status is signed in CPSI, do nothing with the report. Send email with job number and account number to Connie Harrison ([email protected]) with brief description of issue.
RADIOLOGY SPECIFIC
MISSING RADIOLOGY ORDER
DO NOT mark job as complete!
Change the job WT to 9.
Return the job in iNet
Email brief description of issue, account number and job number to Connie Harrison ([email protected]).
DOPPLER ULTRASOUND STUDIES If the physician does not dictate a statement about the technique on a Doppler ultrasound study, insert this statement on the report: Gray scale imaging, color flow Doppler, and spectral wave form analysis of ___ was performed.
RADIOLOGY FORMATTING
Disc, not disk. Do not spell out numbers at the beginning of a sentence when connected with:
o Unit of measurement Examples: TECHNIQUE: 5-mm axial images not Five-millimeter axial images) 5-mm nodule.
o Age/time Examples: 54-year-old female.
Do not spell out numbers in body of sentence, unless a pronoun. Examples:
There is a 3-vessel aortic arch.
There were 6 views obtained.
The one on the right is normal. Do not rearrange sentence word order or add articles like “a” or “an” in front of the numeral.
Example: Dictated as: 2-mm lesion right lower lobe. Correct: 2-mm lesion right lower lobe. Incorrect: A 2-mm lesion right lower lobe.
Spell out numbers at the beginning of a sentence otherwise. Examples: Two cysts are seen in the right kidney. Three views were obtained.
Do not expand abbreviations and acronyms unless nonstandard abbreviation or if on the unapproved list. EXAMPLES: BX = biopsy CA = cancer
TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital
Bleckley Memorial Hospital
02/27/15
46
FX = fracture COPD = COPD DIP = DIP CC = CC if craniocaudal. (CC and MLO views obtained)
Transcribe name of exam at top of report as dictated.
Do not add headers not dictated.
Transcribe text on the same line as header, unless numbered. EXAMPLE FORMATTING: HEAD CT WITHOUT CONTRAST, 02/01/15: TECHNIQUE: 5-mm axial images were obtained through the brain without contrast. No comparison study The calvarium is intact. The paranasal sinuses are clear. There is no evidence of hydrocephalus, midline shift or extra-axial fluid collections.
IMPRESSION: Normal CT brain OR IF MULTIPLE DIAGNOSES IMPRESSION: 1. Normal CT brain - text here if 2 or more diagnoses. 2. Paranasal sinuses clear. - Next diagnosis, etc.
RADIOLOGY BLANKS Contact the radiologist for assistance with blanks at (478) 783-0306.
MAMMOGRAMS
Insert Taylor CAD statement on all mammograms.
Insert Dr. Paul Chandler’s disclaimer on all of his mammograms.
Use the Taylor Shorthand BI-RADS.
Attach CAD order BONE DENSITY/DEXA
Always use the bone density template and fill in values. RED FLAGS See Printing Reports and Faxing Reports instructions
Red flag goes at top of report and in bold. Font should be the same as the rest of the report.
If header shows location as ER, insert ER red flag and print report.
If header shows location as IP with a room number (tayrf), print report.
If header shows location as OP, insert red flag (tayrf) and fax report.