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22. Describe the type of dictation system that is in use. Include any systems that interface with it, the type of reports produced and how control is maintained for quality and quantity purposes. Also answer the following questions:
when was the dictation system last updated?
what are the current systems strengths and limitations?
are there any problem areas related to users?
what are the plans for the future?
If an electronic discharge summary is used, describe how this is produced and the systems that interface with the electronic discharge summary. (Plz, write around 200 words)
According to Judith, Dictation Supervisor, the type of system is voice Recognition, Via Fly) and the last updated was 2009,
Dictaphone Company (Via Fly).There are five transcriptionist working in transcription room, all femal.
Everyone has to finish at least 25 medical records and the supervisor know the productivity of the dictation area as well as for quality and quantity.It allows various types of reports to be dictated (discharge summary, operation report, referral letters, consultations (inpatient and outpation), medical reports, morbidity and mortality reportsand death summary).
1. Most useful and the transcriptionists are familiar with the system.
2. Medical transcriptionists do not need to spend time to inform doctor.
3. Copies of Medical reports, discharge summary, Referral letters and other documents are available on the medical transcription system server as well asLimitation:
1- The transcriptionists can not view it outside the hospital.
2- The transcriptionists cannot view it through google chrome or other websites, only through internet explorer.The plan for future is to implement medical digital dictation system solution, voice reconitaion and to interface with Patient Administration System (eSIHI).
24. Outline the process for an Emergency Department attendance in terms of health information management including:
procedure for an emergency attendance and an admission (new and existing patients).
use of electronic information systems (e.g. Emergency Department Information System EDIS)
purpose and benefits of the system: main users, access and security; interaction with other systems (e.g. interface with Patient Administration System). (350 words)The DEM provides a comprehensive emergency service to all patients presenting to the department on a 24 hours a day 7 days a week basis. The services include:
Accepts all patients with acute illness for treatment.
Triage patients according to a 5-level Canadian Triage Acuity Scale system (CTAS); ensuring patients are assessed and sorted according to acuity
Plan for Assessment, diagnosis, treatment & medical referral for all patients as necessary
Perform emergency medical intervention and resuscitation
Provides advanced Trauma Care to trauma patients.
Liaise with all hospital departments for patient admission and follow up.
Provides care in case of disaster to the community.
o Operates an Urgent Care Center almost continuously to meet the needs of less acute presentations.
o Receives and assesses the stability of direct admissions, including MediVac patients en route to critical care areas within the hospital.
The Department of Emergency Medicine offers emergency health services 24 hours a day to patients of all ages. The department is responsible for the immediate treatment of any medical, surgical or psychiatric emergency, for initiating life saving procedures in all emergency situations and for providing care in a timely manner to all other patients that may present with less serious medical problems. All patients are properly assessed by qualified health care professionals.
Diagnosis, treatment, admission and appropriate referral and follow-up services are initiated here. Intensive care for acute medical and surgical emergencies and emotional problems are provided on a short term basis until the patient is transferred to the appropriate in-patient area. The most critically ill patients receive the top priority care, determined by triage guidelines.
The department of emergency medicine (DEM) is located in the ground floor of the King Khalid University Hospital Building, near the main entrance, in the center of the hospital for easy access. This area can be reached via the main road around the hospital.
Intensive care for acute medical and surgical emergencies are provided on a short t term basis until the patient is transferred to the appropriate in-patient areas. The most critically ill patients receive the top priority care, determined by triage guidelines. The urgent care unit (sub-acute area) offer medical attention for minor emergencies and other illnesses. The sub-acute area is staffed with nurses and physicians
25. Read the hospital policy on confidentiality, privacy and release of information. Briefly document the procedure for the following situations:
internal doctor request to view a health record
external doctor request for specified clinical information
third party request (e.g. to a government agency, insurance company and police etc.)
Freedom of Information request (public hospital): Privacy Act release (private hospital)
previous patient/client enquiry. (450 words)
Internal doctors request to view a health record.
Internal Request to View a Health Record:The internal doctor can request and gain access to health records providing that it is for the purposes of the specific patients specific treatment. There are also provisions in KKUH policy allowing certain health records to be accessed by internal doctors for the purposes of research.
When internal doctors or researchers request the file for studies or research.Please, read the policy and procedures and write the paragraph.
External doctors request for specified clinical information.External Request to View a Health Record:If an external doctor, that is a physician not employed by KKUH, requests specific clinical information regarding a patient, this external doctor must fill in a form and stating why this information is required. This form requires the external doctor to list his or her name, the type of information he wants, the date of request, and to validate the request with a signature. The important things there must be consent from the patient with his details and signature. The Freedom of Information Department (FOI), which is an KKUH only after they have received and are satisfied with the entire requirement, will send the requested information.
Third Party Request to View a Health Record:Government agencies have the executive power to access specific patient medical records without the consent of the patient.Insurance companies generally require the consent of the specific patient in order to access specific patient medical records. These companies must formally request the information include the date of the request, which should be relevant to a time period of less than six months. The FOI monitors these requests very closely and will generally limit the data which sent to the insurance companies to exactly what the organizations requested and no more than that.In relation to criminal matter, the police have executive power to access clinical information. The police are required to send a valid request form. Although it is preferable that the police have the patients consent, the police are able to access data without specific consent in serious cases.Freedom of Information request (public hospital): Privacy Act release (private hospital).Public Hospital Request to View a Health Record:Public hospitals generally require the consent from the patient as well as identification and verification of the person, that is, the employee of the public hospital, requesting the information.The general rule in relation to patient data is that the health care setting is to only use this information for the purposes of diagnosis and treatment.Furthermore, it is also generally accepted that patient data is not communicated to others without the patients consent.These are some of the basic principles of the Privacy Act and confidential communication.With regards to the private hospital sector, when private hospitals ask for clinical information, they are required to send patient request or doctor request with all details and are required to attach consent from the patient.general public enquiry.General Public Enquiry to View a Health Record:General public enquires have the capacity to access broad statistical data about the hospital in different flow of area. However, these general public enquires, such as in the case of a newspaper contacting KKUH, are not granted access to any specific patients information.26. Describe the procedure in response to a subpoena or court order and receipt of a search warrant. (120 words)
Subpoena is an order from the court to produce a record or present a person.
Upon the production of a sunbpoena, a health record must be forwarded to the court requesting it. A subpoena may also require a health professional to attend a trial, produce the documents designated in the subpoena, and give evidence about these documents.
When the subpoena is aIDressed to the Director of Clinical Services, it is acceptable for the record to be accompanied to court by the Medical Legal Officer, Risk Management Department, or nominated officer from the Health record Management Service and handed to the Judges Associate. No one else should receive the record. The signature of the person receiving the record must be obtained, and a note made of the date of receipt and the name of the court.HEALTH INFORMATION SYSTEMS
27. Is the hospital Patient Administration System (PAS) integrated with any other hospitals? Is there a global UMRN? Which other hospitals also use this UMRN? 110 wordseSIHI was implemented at KKUH in May 2015 and is integrated with King Abdulaziz University hospital so if patient has a medical file number at KKUH that means this patient already has file number at KAUH.
eSIHI (Interfaces with other Systems)
PACS (Radiology), Xcelera reports, endosft reports, dictation (via fly), employee Health Record, 3M and medical sick leave will be interfaced with eSIHI. Rest of the system will be interfaces later.
Two hospital use Patient Administration System which called (eSIHI):
Patient Administration System (eSIHI) at KKUH integrated with KAUH.
King Khalid University Hospital (KKUH), a 950 bed hospital and King Abdulaziz University Hospital (KAUH), a 200-bed hospital.
28. Describe the PAS used by the hospital:
which year was the PAS implemented?
are there any plans to replace the PAS?(NO) If so, who is involved in the replacement decision making process?
what is the lead up timeframe from the decision to replace the system to implementation?
provide a brief overview of the PAS , including a list of all modules and brief description of their functions
when and how are hospital reports generated?
discuss the benefits and disadvantages of the existing system
describe the way information flows (this can be a diagram).Describe security management: security procedures and user access levels. Include who is responsible for these areas, the type of training this person has had and their professional background. 300 words
eSIHI was implemented in May 2015.The new company HIS offering will run on the Cerner Millennium software architecture, a highly comprehensive, unified information architecture. Hospitals in the Kingdom adopting this system will recognize a number of important benefits, including:
Improved access to patient information: The creation of an integrated electronic health record for each patient provides real-time access to vital health information, including updated lab results and radiology imagery.
Increased quality of patient care: Electronic order entries eliminate errors caused by illegible handwriting or improper transcriptions, while evidence-based alerts notify physicians of potential complications related to medication interactions and similar situations.
Enhanced operational efficiency: On-time reporting enables hospitals to have greater control over their operations while increasing efficiency and reducing costs.According to the staff, they can know if the patient died or not through the old system, but with this system they cannot know.The new system (eSIHI) is easy to use than the old one and they can see the medical record by scan the barcode.
Please, open this website to understand and answer this question.
Please, see file attachment about eSIHI. The name of file is (Important thing should Know about eSiHi)29. Describe the Patient Master Index/Central Patient Index/Master Patient Index and how it is maintained. Include:
the purpose of the Index
who creates the data and has the authorisation to update
allocation of the unit health record number and any associated tasks (e.g. creation of a health record file)
brief description of information recorded (mandatory data items, aliases, alerts)
methods of verifying and updating patient demographics
how potential errors are identified and managed
controls in place for ensuring data is completely maintained (quality and accuracy).
Consider and include: clerical and other staff training and access, error messages, risk management (e.g. duplicate numbers: why created, consequences, prevention). Around 350 wordsThe Patient Master Index is a database holding all patient information within the hospital
Demographic information relating to inpatients, outpatients and surgical day-care is maintained in the CPI database. It also maintains all patient historical data in the facility. The main purpose of CPI is to create UMRN and ensure that one patient equals one UMRN.
CPI and A&E are able to create a patient medical records number, but only CPI is able to update patient demographic details.
CPI needs to display any alert in the system that would flash to notify the health professional.PMI Update:
The data inputted into the PMI may be updated by relevant and authorized documentation clerks, emergency clerks, and laboratory clerks.Unit Medical Record Number (UMRN):There are Three areas for creation of medical record:
1. Employment Clinic.
2. Emergency Department.
3. Eligibility office.Mandatory Data:Are patients data which going to be register in the eSIHI? These data are: Surname, given names, date of birth, national ID, aIDress,
UMRN Inactivated/Merged in Error:
When an incorrect merge/inactivation has been identified implement the site specific procedures for dealing with this occurrence.All systems using eSIHI data via interfaces will ensure that the data is held against the correct UMRN. A script will then be run to point the inactivated UMRN to the correct new UMRN registration for that patient.
Notifies supervisor, of duplicate file numbers or names, so that corrections may be made.
Receive patients details and to take evidence (proof) for integration of the medical record file.
Make sure the number(s) and the name of patient is identical before merging.
A request is made to review the file and check for ward admissions of the patient through the HIS (Hospital Information System).
A request is made to review the file and check for ward admissions of the patient through the eSIHI.
Checking of the entries in multiple medical records to ascertain the identification.
ID or Family card of the patient is to be matched with the details of the multiple medical record files and match the entries.
One medical records number is retained and the other file (s) is cancelled. The patient is to be notified of the number retained and the one cancelled.
All details of other medical records is incorporated into one MRN number.
Send sample to merge the files directly to the IT department.
Strategies for Avoiding Duplicate Patient Numbers:Notifies supervisor, of duplicate file numbers or names, so that corrections may be made.
30. Describe what is meant by downtime. Has the facility ever experienced any significant downtime? If so, what was the cause and for how long were systems down? What lessons were learnt?
1. How often does downtime (non-significant) occur? Why does it occur?
2.Downtime can be scheduled. What is the purpose of this? How often does it occur?
3.Document the Downtime Procedure/s for Emergency Department admissions officers.
(Around 500 words)Downtime:
Period of time that a system fails to provide or perform its primary function. This could occur as a result of computer system failure, interface failure, software failure, network failure and/or routine planned maintenance and upgrades.According to staff at KKUH, downtime with regards to HIMS is not often occurring at the setting. The last time was two months ago and only for almost half hour and this happened in only emergency department. The SIHI is new for all staff at KKUH.
3.2 Planned Downtime:
Period of scheduled downtime during which the system is not functioning properly or is unavailable to users due of scheduled maintenance, system updates and upgrades.3.3 Unplanned Downtime:
Period of unscheduled downtime during which the system is not functioning properly or is unavailable to users due to system or environmental failure . 3.4Downtime Phases:
Phase I: Downtime equal to or less than 1 hour.
Phase II: Downtime greater than 1 hour but less than 4 hours.
Phase III: Downtime greater than 4 hours.
B. Ambulatory & Emergency Department:
Physicians in charge in the unit will be responsible for all kinds of documentations during down time & ensuring instant scanning.
Unit nurses/clerk: responsible for provision of all paper forms during down time, instant scanning & uploading documents when system is recovered.
Down Time support Team (DTST): responsible for uploading scanned documents & entering orders in eSIHI when system is recovered before the end of the dayB.1 Documentation:
During Down Time: Specific forms (new patient visit notes & progress note) will be completed by the physician in charge. Paper forms will be used then will be scanned.
After system recovery: All orders will be uploaded by Clerks/DTST B.2 Referrals / Labs & Radiology Orders:
During Downtime: Physician in charge is responsible for making orders on paper request forms.
After system recovery: All orders will be uploaded by Clerks/DTST. B.3 Medication Orders:
During down time: Physicians order on ordinary prescription forms. All prescriptions are printed out by default & given to patients. (policy number TITLE) Page 7 of 19
If system is down after physician made his entry in eSIHI& before patient gets medication from pharmacy: Prescription print out may be obtained from back-up system/hard drive..
After system recovery: Pharmacy will enter medication orders in eSIHI& send to physicians for co-signature. B.4 Communication:
All communication orders followed during regular daily work must be maintained during down time, e.g.: consultations & referrals, transfers, reporting critical problems & resultsetc.
All must be documented in eSIHI, when system is active.Admission During Downtime:Registration of all admitted patients (inpatients, & ED) will be the responsibility of Admission office.
1.1.1 The admitting department will complete a manual ADMISSION face sheet for each patient admitted during downtime.
1.1.2 The patient will be sent to the unit with the following documentation:
The manual ADMISSION face sheet
Patient admission orders ( if available)
Patient labels and armbands
If the patient does not have a copy of his or her admitting orders, the Nurse or appropriate designee will call the admitting physician for Admission orders. If the Admission is generated by the nursing unit (in the case of a newborn, for example) the unit will call Admission desk to notify them of the new admission.
The Unit Clerk/designee will establish chart for the patient using a downtime packet. Each page will be labeled with the patients name, medical record number or FIN NUMBERS, room and bed, and admitting physicians name.
1.1.3 Due to the increased potential for errors during downtime, it is necessary to limit discharges.
1.1.4 The discharging unit will call Admission desk and notify them of the discharge.
1.1.5 The downtime documents will be aIDed to the patients chart and maintained on the patients nursing unit until the recovery process is complete, then follow 5.3 Data Entry.
Documentation During Downtime:
All downtime forms must be labeled accordingly with two patient identifiers (name and date of birth at a minimum).
The downtime forms should be dated, timed, and signed.
Nurse indicates Allergy on top of each medication order.
All paper forms will be filed as part of the patient medical record.
HIM (Medical Record Department) Procedure:
Downtime related issues in the medical records department.
Print all the patient lists and pull the files as normal. Once the downtime is restored, Medical Record Files tracking is done. (policy number TITLE) Page 14 of 19
Request: If there is a backup then the request is sent manually to the respective units and once the downtime is restored, Medical Record Files are updated.
All work is done manually and the requests are stored. During such an event no coding, no deficiency tracking, no transcription.
For the processing of medical records, it could be done manually by getting them from the wards and processed in the unit.
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