Medical Records
There are 4 main parts to Medical Records:
1) Patient Routines – Demo Recall, MPI (fix patient records)
2) Incomplete Records – replace/fix deficiencies
3) Record Locator – track where records are (sign out/transfer/return)
4) Correspondence – track requests for information
Patient Routines
Master Patient Index (we can add new or edit existing patients here) - You have access to all patients that have a
Medical Record # - you can pull them up by a partial name lookup
Discharge Disposition – last date of discharge disposition (if entered in ADM
Record Locator – shows if any part of the patients’ record is checked out
Portion Out/Incomplete – shows if any portion of the record is out or incomplete
The bottom part of the screen shows previous visit(s) information from admissions. You can also attach a CDS
here if you want to capture more information.
After we have loaded all our files into the live environment, we must manually enter new patients here (during
lag week – there is a hand out called lag week explaining what will happen during this time). In July (about 1
week before we go live) is when all this will start.
Some of the other options on the Patient Routines Screen are:
Master Patient Index – View Detail – you can only view patient information and not make any changes
Master Patient Index – View Summary – Shows the same information as view detail, but instead of showing
each recurring visit individually, it shows just a # of recurring visits with no detailed information about those
visits.
Print – Can print the detailed or summary information
MPI Maintenance
Delete/Restore – you can delete a patient or if you accidentally deleted them you can restore them (only if you
know their Medical Record # - you can’t look up by name)
Merge- you can merge two records if the patient somehow got entered twice
Unmerge – take the two records you just merged into one and separate them back into two.
Before you can merge/unmerge, you must run compile duplicate patients and that will show you a list of when
that report was run the last time and will then bring up a list of possible duplicate patients. Only compare
records that were created on/after the date last run so you won’t miss any.
Birth date Range – usually 30 on how many days different can the birthdate be to possibly be a match
Last Name – use Soundex Match – looks for possible misspellings of the person’s last name
First name – can do exact, soundex, first initial only, or ignore
Press F12 and it will run. Next go to MPI Maintenance and Print Duplicate Records. If there are duplicates then
run the merge routine.
Patient Fast Input (usually only used during lag week) - to quickly add a patient (have to type in the next
medical record # and then the patient data).
Patient Fast Search – shows patient name and Medical Record #
Unit # - shows the next unit number that is to be assigned – you can also change what you want the next unit #
to be
Verify Daily Assignments - shows the unit #s that have been assigned that day so you can verify they are
correct
Edit – if they have the wrong unit # you can change it. Down at the bottom it shows the old MR#. If Delete is N
it will allow you to type in the old MR# and you can make any changes you want
Increase Unit # - you can bump the next unit # up to whatever you want it to start at
Critical Care Indicators – allows you to capture any information on a patient that you think is critical care. You
must create a CDS in MIS and then pull it in here – can be information that you want captured during
admissions.
Duplicate SSN report- prints a report if more than one patient has the same SSN
Logs/Reports – all the different reports that can be run:
Monthly Assignments by name – shows all patients assigned a medical record # during that time frame sorted
by unit #
Monthly Assignments by Unit # - shows all patients that were assigned a medical record # during that time
frame sorted by unit #
Fast Input Log – shows which users used the fast input
Delete/Restore Transactions – shows which records were restored/deleted
Merge/Unmerge Transactions – shows which records were merged/unmerged
Edit Transactions – shows any edits made to a patients file
Missing Patient Data – If any patient data is missing from MPI it shows that information here (this report can be
deceiving because it shows other name or maiden name is missing which is most patients)
Alt Patient Address – shows if changes were made to the alternate address or phone information
Demo Recall
Edit – you can edit demo recall information
The Restrict Dir Discl - will restrict patient information from showing up in directories for patient or religion
lists
Demo Recall Audit Report – shows any changes made to an EMR
Incomplete Record Routines
Use these routines to add/remove deficiencies on patients
Process – place deficiencies on an account
You pull up a patient and then put in the portion of the record that was incomplete (it is a free text field).
Most of the time it is a Volume (be consistent when entering these – like Vol 1 or Volume 1) or
Admit/Discharge Date missing. The box is which doctor box it goes into.
Doctor Available is the doctor responsible for the deficiency
You can keep on going adding as many deficiencies for multiple doctors if needed. After you save it shows a
report of what was just done (there will be a different page for each doctor).
Suspend/Resume Incomplete Record Process – we will not use this because we have the link turned on!
Print Deficiency By Doctor – pick record and account # and it will list by doctor what is incomplete
Complete ICR for one doctor – if a doctor signs off on a bunch of incomplete records you can use this to mark a
bunch of them complete – much quicker than one record at a time!
Delete – you can delete a deficiency if it was put on there in error. CAUTION – it will delete ALL deficiencies
for that account! If you want to get rid of only 1 deficiency you will need to go to process and delete it there.
E/E Doctor Availability – if a doctor can’t sign records (sick or on vacation) you can tell the system how long
they are unavailable and it will stop counting days to process.
E/E Doctor Info for Visit Log – log that the doctor came in and what for
Addl ICR Routines
ICR Count – list of all ICR in system
Delinquent Record Count – determined by patient status if it is delinquent
Print Record Incomplete – prints what is incomplete about a record
Audit Inquiry – shows the different actions that were taken on an incomplete record
Productivity Report – shows by user what they have been doing
E/E Del days for Pt Type – determine how many days before a patients record is considered delinquent
E/E Default Date Available – enter the date we want the incomplete record to appear under the process icr
routine (when in process icr this will be the date that auto appears under date available)
Print Notification Letter – prints a letter to the doctor showing what deficiencies he has. Use a number as the
mnemonic and this will be what drives the # of overdue days when printing the letter
System Management – Dictionaries – Letters
Here is where you create the notification letters that we want to print.
F5 (Get Key) then type f and a space then hit F9 and it will pull up the data fields that we can have auto fill in
our letter
The fields for notification letter prompt is if we are using (f mri dr inc pt info c) we can have this info shown by
what is placed in these fields
Incomplete Record Lists - will print icr by different criteria sorted various ways
Record Locator Routines
Sign out/Reserve
Recipient – where the record is going
Record – which record or patient
Portion (Volume 1 or Vol 1) KEEP CONSISTENT on how we type this in
Sign out for one recipient – if a dept wants more than one record enter them here
Reservations
Move record – if another dept needs a record right away that is already checked out, us this to move it to
their dept
Reserve Record – if someone else has the record, you can reserve it when it is returned it will be sent to
you
Locator Inquiry
View Record – shows where the record is
Audit Trail Inquiry – shows where a specific record has been
Recipient Inquiry – shows what dept has checked out/reserved/has now
Locator Lists
By Terminal Digit – Not Applicable for us
By Recipient – lists all recipients and what records they have
List Reservations – show who has what records reserved
Recipient Inquiry – (same as under locator inquiry – just a shortcut)
Letters/Reports – can create reminder letters for record locator under system management – dictionaries –
letters (they type will be a locator)
Productivity Report – Shows who has processed and the number of records they processed
Correspondence Routines
Enter/Edit Requests – log requests for information
If it is new put in a N and it will put in the next available number
Status (Logged/On Hold/Complete) – will be logged the 1st time
Type – what type of request is it
Unit # - put in patient
Date Needed – when do they need the information
ID Verified – have you verified the id of who is requesting
Comment – might put in how the ID was verified
Requestor – F9 Shows requestors
I space F9 will look up into insurance dictionary
D space F9 will look up into provider dictionary
R space F9 will look up into recipients’ dictionary (our dept)
Pages – how many pages will it be
Fee – how much is the fee for this
Paid – have they paid the fee
Requested information – what do they want
On Hold – reasons why the request isn’t being sent out
Phy Approve – did the physician approve it
Phy Mnem – the doctor who approved it
Process Requests
Can add new/enter requests (multiple at one time)
Print requests or letters
Complete requests
Save list of requests
Compile Reports – we can set certain criteria and the system will look for all records that match that request
Select Fields – different fields that we can pull information from
Pick the fields and set the criteria for what you are looking for:
This prints any correspondence that has an unpaid fee:
Select Field
Any Reason
Index
N
INC
I
From
Fee
Thru
Fee
Press F12 to start then go to compiled reports and print reports
Purge reports – delete a report out of the system
Halt – will halt a report if the compiling is taking too long
Productivity Report – shows by user how many correspondences were done
Abstracting
Project Dictionary – this is where you assign the CDS to an abstracting patient
Special Study – If you want to flag a patient for a special study, put that study in here (like used restraints)
Process a Patient
Process Abstract – can do an F9 or partial name lookup
Abstracting - Reports – Screens to be Refiled – all patients that need to have screens in their accounts refiled
will be when this is run