As part of our desire to improve patient care we expect that all patient care documentation will occur in a timely manner. Documentation is a basic part of communicating between providers and is important in documenting the care we provide to our patients. A national patient safety goal is aimed at documenting as soon as possible to improve the quality and timing of the note.
For those of you who use the dictation system we have seen a large number of documents that are dictated well after care is provided. An additional significant delay occurs in reviewing and signing those dictations. Unsigned dictations using the electronic signature system, Esig routinely exceed 1000 records on any given day, and many thousands of unsigned verbal orders remain as well.
Unsigned dictations are not considered finalized for patient care, legal documentation, billing or compliance/regulatory reasons.
Both the Medical Executive Committee and the Medical Informatics/Records Committee have approved the following MINIMUM standards for record completion, to be implemented immediately
Operative Reports: To be dictated within 24 hours/same day of surgery (old standard 3 days)
Discharge Summaries: To be dictated within 7 days of discharge (old standard 10 days).
Signing of Esig documents: To be signed within 2 weeks
Verbal Orders Co-sign: Current policy requires these to be signed within 24 hours.
Please make every effort to comply with these standards to avoid sanctions and loss of privileges, as well as to provide excellent patient care
Thank you for attention to this matter.
Rich Molteni, MD