MEDITECH
Medical
Records
functionality brief
The Medical Records functionality in MEDITECH's Health Information Management product provides multiple and single facility health care organizations critical patient identification and medical record functions to integrate care delivery. For each facility in the organization, the application ensures a common means to identify patients and to correctly apply all care information for previously admitted patients.
Equally effective in a small organization as it is in a large enterprise, this Enterprise Patient Index (EPI) is a shared database of demographic, insurance, and visit history information for every patient in the integrated care delivery system.
Highlights:
• Easy addition of new patients for
multiple facilities, with demographic and insurance information
stored in a single file that is accessible across the enterprise
• Separate patient numbering schemes for
different facilities, to prevent duplicate records and
misidentification of patients
• Record locator functions assist with
tracking medical records via audit trails, reminder letters, and
reports
• Tracking for incomplete medical records
links with transcription features in the Imaging and Therapeutic
Services application, for automatic generation of deficiencies
• Electronic Signature capabilities
• Correspondence feature organizes
requests as well as generates letters and reports to help
organize workflow and revenues.
Standard
Features
Efficient
Addition of New Patients and Managed Care Members
The functionality allows all providers in your enterprise to add
new patients at any time.
• New patients can be added by any facility, whether it is
using MEDITECH's information system or another vendor's system
• All members on the enrollment database are automatically
assigned to the EPI. Therefore, demographic and insurance
information for all managed care members is on-line at all
enterprise facilities before members schedule their first
appointments
• When a patient visits a facility within the enterprise for
the first time, or calls for his or her first appointment,
registration and scheduling personnel create a new record. All
pertinent demographic and insurance information is collected and
then stored in a central file across the health care enterprise.
Positive
Patient Identification
Positive identification within the EPI eliminates duplicate
patients. Some features include:
• Providers can search by name, partial name, sex, date of
birth, Social Security number, or by Soundex search
• At the point of admission, registration personnel have the
option to view patient pictures on-line
Clinical
Histories
The functionality also stores basic clinical history information
and makes it available to all providers. This first level of
clinical information on a patient includes:
• A visit history which lists visits, providers visited, and
date of visit
• A history of the patient's encounters
• A list of all the patient's visits, along with the
diagnosis associated with each visit.
More in-depth clinical information is reserved for the Enterprise Medical Record (EMR). The EMR contains all aspects of clinical information from each visit conducted along the continuum of care. In order to protect patient confidentiality and security, records can be sealed so only specific users will have viewing access.
Individual
Facility Identification
Individual providers across the enterprise maintain the separate
patient numbering schemes required at their own facilities. While
all providers participate in the enterprise-wide patient
identification system, individual facilities also have their own
numbering systems for internal management functions.
The EPI supports both the facility-specific numbering for individual providers and the universal "one number, one patient" scheme that is crucial for enterprise management. This assures that there is no duplication of patients nor confusion in patient identification.
Process
Patient Worklist
The process patient worklist allows users to perform multiple
functions on one patient or a list of patients within a single
routine. By selecting a search criteria, users have the ability
to sign out/return records, process incomplete records, and track
correspondence requests.
Tracking
Medical Records
From any workstation, users have the ability to locate and review
all medical records residing on the HCIS. Patient information can
be retrieved from any computerized department within the hospital
or at remote sites such as physicians' offices or satellite
laboratories.
• Record locator functions provide an efficient method for
tracking medical records and maintaining on-line data about each
recipient. These locator functions:
– print reminder letters and reports
monitoring location of the records checked out
– enable users to view any record and
display the record's current location
– generate an audit trail and recipient
inquiry
– list locator records sorted by terminal
digit, recipient, or reservation
– enable users to reserve records
– allow records to be moved from one
location to another without having to return and sign the record
out.
• Bar code capabilities facilitate record reading and data
entry
• Linking of the incomplete records and record locator
functions expedite tracking of incomplete records and allows for
automatic reservations and returns
• Batch Sign Out and Reserve Record routines allow users to
process records being signed out to a recipient.
Incomplete
Medical Records Check
Medical Records functionality helps users define which records
are incomplete and the care providers responsible for completing
them. The system generates:
• Tallies, by physician, on the number of days each medical
record portion is considered incomplete
• Notification letters and several lists, including:
– Incomplete Record Lists (Days
Outstanding, Terminal Digit, or Name)
– Doctor Incomplete Lists (Days
Outstanding, Terminal Digit, or Name)
– Incomplete Record Count
– Delinquent Record Count.
• A batch routine to expedite the process of completing many
records at one time
• An audit trail signifying the user, date, and time for
incomplete records processing, which lists who entered, deleted,
and/or completed a record
• A link to transcription features within MEDITECH's Imaging
and Therapeutic Services application which allows deficiencies to
be automatically generated and completed via electronic signature
• Automatic deficiencies for history, physicals, and
discharge summaries not transcribed within the facility-defined
time frame.
Correspondence
Feature
A Correspondence Feature provides a medical records department an
efficient tool for tracking requests for medical information,
generating reports for monitoring workflow and revenues, and
printing letters and reports of correspondence. These functions
allow an organization to oversee the processing of requests for
medical information from the time the request arrives at the
medical records department to the time a staff member sends the
requested information.
Medical
Records Maintenance and Control
Several reports are generated that help health information
administrators review activities taking place throughout the
health care organization, such as:
• Verify Daily Assignments
• Unit Number Assignment Log
• Edit Transaction Log
• Monthly Logs of New Medical Records
• Merge/Unmerge Transaction Log
• Duplicate Patient Report
• Duplicate Social Security Report
• Delete/Restore Log
• Missing Data List
• Population Count
• User Activity Log.
For more information about us, contact a MEDITECH Marketing Representative.
MEDITECH
Medical Information Technology, Inc.
MEDITECH Circle
Westwood, MA 02090
781-821-3000
www.meditech.com