Health Information Management (Medical Records)

Contact Information

Mary Garcia, Director, 670-6516
Jerry Campbell, Supervisor, 670-2496
Martha Davis, Supervisor, 670-2247
Eunise Diaz, Data Specialist, 670-6316
Medical Records Incomplete Chart Room, 670-2901

Please e-mail the Medical Records director with a courtesy copy to the data specialist at least a week prior to being out of town for more than a few days so records will not be counted incomplete in your absence. This does not exempt you from completing all available records prior to your departure.


Dictation/Adult Ordering

To dictate from within the hospital, dial 4411.

From outside the hospital, dial 325-670-4411.

  • To begin, enter physician number, then #.
  • Then enter the digit for the corresponding work type, followed by the # sign.
  • Enter the medical record, followed by the # sign.
  • Press "2" to dictate, then begin dictation.
  • State your name, they type of report and the patient's first and last name.

Work Type Numbers

1 History and Physical
2 Inpatient Consultation
3 Operative Report (includes procedures)
4 Endoscopy
5 Heart Catheterization
6 Discharge Summary
 
7 Bronchoscopy
9 EEG
10  Heart Failure
11 Progress Notes
12 Trauma Center Note
   
 

If at any time during the report, you decide this must be a high priority report, press the # sign twice (##) to make it STAT. Then, press the number 2 to continue the dictation.


Medical Records Policy




Clinical Documentation Integrity Program

CDI Program

The goal of Hendrick Medical Center’s Clinical Documentation Integrity (CDI) Program is to clarify ambiguous, conflicting or incomplete documentation. Our CDI Program helps ensure that physician documentation accurately paints the clinical picture of the patient, thus reflecting the integrity of the clinical, quality and safety outcomes.

Clinical Documentation Coordinator

The clinical documentation coordinator works to facilitate the overall quality and completeness of clinical documentation to accurately represent the severity, acuity and risk of mortality profile of the patient. Focused communication with the treating clinical professionals (i.e. queries) will be utilized to obtain improvements in documentation.

Our CDI coordinators are experienced registered nurses with strong clinical backgrounds, who are proficient in ICD-10 terminology. They review clinical documents and provide feedback to physicians and mid-levels to fill the gaps in documentation. Questions might include clarification in coding, quality measures and overall care management of a patient. Additionally, CDI coordinators act as a bridge between the providers and certified coders to close any documentation gaps.

Why query?

A query is a routine communication and education tool drafted by a CDI coordinator or a certified coder after review of the medical record. Concurrent queries are initiated “real time” during the course of the patient encounter or hospitalization at the time the documentation is naturally done.

The query provides:

  • Accurate profiling ((risk of mortality (ROM), length of stay (LOS) and severity of illness (SOI)
  • Improved specificity of coding data, as evidenced by accurate capture of co-morbidities (CC) and major co-morbidities (MCC)
  • Support documentation requirements needed for current accepted professional coding practices and convention following ICD-10 Guidelines
  • Accurate reimbursement for services rendered, complexity of care and resource utilization

Provider benefits:

  • Improved patient outcomes and patient satisfaction
  • Better data for creation of benchmark physician profiles, physician quality scores and how coding defines the expected LOS, core measures, hospital-acquired conditions and patient safety indicators
  • Better recognition of patient co-morbidities thereby accurate capture of a patient’s SOI, ROM and CMI
  • Improved operational efficiency in healthcare organizations
  • Decreased risk of conversion to observation stay
  • Performance metrics-utilization of SOI and ROM
  • Complete and consistent records for patient care and data collection
  • Support CMC Value Base Purchasing Program

Hospital benefits:

  • Documentation is necessary for complying with quality measures
  • Quality information supports care management and making sure protocols are followed
  • Documentation supports coding, which is the basis of correct revenue and reimbursement

Helpful Tips:

From the Physician Advisor

  • Make sure accurate diagnoses are coded to the appropriate level
  • Include daily appropriate documentation when writing each day’s note, including query responses
  • Upgrade daily or add any new diagnoses to the problem list at the caduceus symbol in Apollo

The discharge summary will be the judge of what physicians will be paid. It’s not about volume, it’s about levels of service.

CDI Team:

Mariela Agosto-Rivera, MD
Clinical Documentation
Physician Advisor
325-670-6410
twilliams@hendrickhealth.org

Mary Garcia, RHIA
Director, Health Information Management
325-670-6516
Room 6523
mbgarcia@hendrickhealth.org

Tess Tolentino, RN, BSN, PCCN
Lead Clinical Documentation Coordinator
325-670-6511
Room 6509
ttolentino@hendrickhealth.org

Julie Snow, RN, BSN
Clinical Documentation Coordinator
325-670-6571
Room 6511
jsnow@hendrickhealth.org

April Songer, RN
Clinical Documentation Coordinator
325-670-6504
Room 6512
asonger@hendrickhealth.org

Amber Parrish, RN
Clinical Documentation Coordinator
325-670-6574
Room 6510
anparrish@hendrickhealth.org

 

 

 

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