taylor health account specific guide taylor regional

TAYLOR HEALTH ACCOUNT SPECIFIC GUIDE Taylor Regional Hospital

Bleckley Memorial Hospital

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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



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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]

mailto:[email protected]



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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

http://www.taylorregional.org/trustedsite.vbs

http://receiver.citrix.com/

https://secureconnect.taylorregional.org/

http://dacsolution.com/support/manuals/iNet_3_User_Guide.pdf



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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



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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:



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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:



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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.



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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.



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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



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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.



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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.



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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



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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



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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)

https://cphelp.cpsi.com/v19/ptmgt/him/index.html



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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.



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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.



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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



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U – Unsigned S – Signed

REPORT TYPES Click on PgDn to see all report types.

BLECKLEY

TAYLOR



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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)

https://cphelp.cpsi.com/v19/clinical/rad/index.html



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Transcribe Orders

Enter Patient Number

Radiology

Transcribe orders

Status changes to Transcribe Mode



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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



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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:



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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



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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



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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



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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.



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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



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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



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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.



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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



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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



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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)



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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



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Yes

Hold

Delete

Type YES, continue



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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



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Sort by Physician

Print

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



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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



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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.



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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



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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.


Enter Beginning and Ending dates.

Do not place check mark in All Dates field.

Number of Copies: 1

Print



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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.




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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






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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:




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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.




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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.




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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





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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.

taylor health account specific guide taylor regional

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