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/policies/administrative/uw-health-administrative/health-information-management/615.policy

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100

UWHC,UWMF,

Policies,Administrative,UW Health Administrative,Health Information Management

UW Health Medical Record Documentation (6.15)

UW Health Medical Record Documentation (6.15) - Policies, Administrative, UW Health Administrative, Health Information Management

6.15

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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Foundation (UWMF).


Policy Title: UW Health Medical Record Documentation
Policy Number: 6.15
Effective Date: August 23, 2017
Chapter: Health Information Management
Version: Revision


I. PURPOSE

To establish policy defining medical record documentation requirements. Maintaining and improving the
accuracy of clinical documentation can reduce compliance risks, minimize UW’s vulnerability during
audits, and has proven to be instrumental in affecting quality measures.

II. DEFINITIONS

A. Closed Medical Record - the completed medical record as it appears for filing. The record will
have been reviewed for completeness by Health Information Management or the appropriate
outpatient clinic and subsequent completion by care providers accomplished. The closed medical
record consists of paper documents and the final results of computerized/automated systems to
include tracings, printouts, images and text. Documents requiring authentication are to be
authenticated by manual signature on paper documentation or electronic signature on electronic
or dictated documentation.
B. Open Medical Record - the medical record as it appears during the evaluation and treatment of
the patient. The record may consist of computer generated reports, handwritten entries, results of
tests, interpretations, tracings, images and reports viewable from department or diagnostic
systems (i.e. laboratory, radiology, HIM, etc.) and the electronic medical record.
C. Separate Primary Records - (Subcharts) contain documentation that would be considered a part of
the UW Health primary medical record. Subcharts are located and maintained in areas other than
within Health Information Management files. Requests to maintain a subchart are no longer
approved and existing subcharts will be eliminated as UW Health moves toward an electronic
medical record (see Administrative Policy 6.28-Procedures for Approval & Elimination of
Existing Subcharts & Shadow Charts to the UWHC Primary Medical Record).
D. Shadow Charts - contain copies of documents in the UW Health primary medical records utilized
for reference in areas other than within Health Information Management files. As the electronic
medical record becomes the primary source of clinical documentation, departments are strongly
encouraged to destroy existing shadow charts (see Administrative Policy 6.28-Procedures for
Approval & Elimination of Existing Subcharts & Shadow Charts to the UWHC Primary Medical
Record).



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III. POLICY ELEMENTS

A. Patient care staff shall be responsible for the preparation of a current, complete and legible
medical record.
B. The chief of service and department chairs shall be administratively responsible for ensuring that
physicians and non-physician providers within their respective departments complete medical
records in accordance with standards adopted by the Medical Board.
C. Rules established by the Medical Record Committee and Medical Board regarding the use of
symbols and abbreviations in the medical record must be followed (see UW Health
Administrative Policy 6.18-UW Health “Abbreviation Listing” and “Supplemental Abbreviation
List “
D. Signatures must be handwritten or electronic, depending on the documentation source. Signature
stamps and digital images of manual signatures are not allowed.
E. All entries in the medical record shall be signed, dated (including year) and timed. This rule
applies to physicians, nurses, and all other persons who make entries in the medical record.
F. All documentation should be electronic or written using permanent black or blue ink. White-out
or other means of obliterating documentation is prohibited. Refer to Administrative Policy 6.14-
Amendment of the Medical Record for directions on correcting or amending a medical record
document or to the Health Link Chart Corrections Guidelines located on U-Connect.
G. Patient care summaries or other similar records should not be prepared from memory. The
original source documents (e.g. laboratory or radiology reports or medication administration
records) should be in the transcriber's or dictator’s immediate possession or view when it is
necessary to transcribe or dictate information from one document to another.
H. Unsecured text messaging should not be utilized to communicate protected health information.
I. Release of medical information shall be in accordance with policies established by the Medical
Record Committee, the Medical Board, and Wisconsin and Federal laws. (Refer to the following
Administrative Policies and Procedures: 4.10, 4.13, 4.14, 4.16, 4.30, 4.38, 6.20, 6.23, 6.24, 6.30,
6.33, and 6.34).
J. All medical records, inpatient and outpatient, are the property of UW Health and will be made
available for peer review, legal, or other legitimate UW Health purposes. Medical records should
not be removed from UW Health's jurisdiction and safekeeping, except in accordance with a
court order, a subpoena duces tecum, or state statute.
K. Requests to maintain a separate primary record (subchart) from UW Health record are no longer
approved and existing subcharts will be eliminated as UW Health moves toward an electronic
medical record. (Refer to Administrative Policies 6.26-Medical Record Retention Policy and
6.28-Procedures for Approval and Elimination of Existing Subcharts and Shadow Charts to the
UWHC Primary Medical Record).
L. It is the responsibility of all patient care staff to document all patient care in the medical record.

IV. PROCEDURE

A. Inpatient/Observation
The medical record should be completed within 14 days following discharge, however it is
strongly encouraged that the medical record be completed within 7 days. A complete inpatient
medical record shall include, so far as applicable: identification data (when not obtainable, the
reason must be entered); medical history; relevant physical examination; diagnostic and
therapeutic orders; evidence of appropriate informed consent (when not obtainable, the reason
must be entered); clinical observations, including results of therapy; reports of procedures, tests
and the results; conclusions at termination of hospitalization or evaluation/treatment; and
discharge summary.

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The attending physician is ultimately responsible for the preparation of a current, complete and
legible inpatient/observation medical record.

1. History and Physical Exam (H&P)
a. A history and physical examination shall be recorded within 24 hours after the patient
physically arrives for admission/registration, but prior to surgery or a procedure
requiring anesthesia.
b. H & P shall be recorded by a member of the attending staff, Graduate Medical
Education (GME) trainee, or physician assistant or nurse practitioner under the
supervision of the attending staff. Under special circumstances, such as when
emergency measures must be taken immediately, a brief admission note may be
recorded pending completion of the history and physical examination.
c. The minimum content of the H&P includes:
i. Chief complaint
ii. History of present illness
iii. Relevant past history, allergies and medications
iv. Relevant physical examination, to include heart/lung evaluation
for pre-surgical patients
v. Psychological and social assessment, if appropriate
vi. Treatment plan
d. If an H&P is recorded by a physician assistant, nurse practitioner, or a GME trainee,
the attending physician is required to countersign each record within 24 hours after
the patient physically arrives for admission/registration, but prior to surgery or a
procedure requiring anesthesia and either approval of the H&P or disagreement, with
any appropriate revision(s).
e. The H&P may be performed up to 30 days prior to admission/registration, but prior
to surgery or a procedure requiring anesthesia. An update of the patient's condition
after examination, with any changes noted, must be documented in the record within
24 hours after admission/registration but prior to surgery or a procedure requiring
anesthesia.
f. A properly executed H&P is valid for the entire length of stay. Any changes to the
patient’s condition would be documented in the daily progress notes. A new H & P
or update to the H & P is not required when the patient
remains continuously hospitalized.
g. Re-admission to the Hospital within 30 days for observation or treatment of the same
or related condition requires only an interval history and the recording of significant
changes from the previous physical examination. The note should review the period
since the patient's last discharge, refer to the previous history and record any
significant change in physical examination.
h. An H&P performed by a patient's local physician/NP/PA (non-UW Health) within 30
days prior to patient physical arrival for admission/registration, but prior to surgery or
a procedure requiring anesthesia, may be used provided the attending physician
indicates review, examines the patient, makes any necessary additions, and signs,
dates and times the note within 24 hours after the patient physically arrives for
admission/registration, but prior to surgery or a procedure requiring anesthesia.
i. Any H&P completed greater than 30 days prior to admission/registration, but prior to
surgery or a procedure requiring anesthesia cannot be updated and a new H&P must
be completed.




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2. Progress Notes
a. Progress Notes should give a pertinent chronological report of the patient's course in
the hospital and reflect any change in condition and the results of treatment.
b. All notes should be dated (including the year), with the time of day noted, and signed
by the writer who will identify his/her position.
c. A progress note for each patient must be entered daily by the attending physician. A
GME trainee, physician assistant, nurse practitioner, or medical student note which
clearly states the presence of the attending physician and is countersigned, dated and
timed by the attending physician satisfies this requirement. In addition, the
supervision of GME trainees and medical students must be verified either by mention
in the daily attending physician note or by the attending physician's co- signature
(dated and timed) of the progress notes entered by GME trainees and medical
students.
i. For inpatients whose daily care is being managed by a nurse practitioner
(NP) or physician assistant (PA), a daily note by the NP/PA satisfies this
requirement. It is expected that the attending physician is supervising the
patient’s care throughout the hospitalization and completes the admission
history and physical and discharge summary as detailed in this policy.

3. Informed Consent
a. Informed consent of the patient must be obtained and documented as required by
Administrative Policy 4.17-Informed Consent.
4. Operative Notes
a. An operative note is required for all operative and high risk procedures..
b. The responsible physician should record and authenticate a pre-operative diagnosis
prior to operating.
c. Operative reports should be directly entered into the electronic medical record or
dictated after surgery before the end of the next business day. The report will contain:
i. description of the procedure,
ii. findings,
iii. specimen(s) removed or altered (if applicable),
iv. postoperative diagnosis,
v. estimated blood loss (if applicable), and
vi. name of the primary surgeon and any assistants.
A deficiency notice will appear in the attending surgeon’s Inbasket folder if the full
operative note is not completed by the end of the next business day.

d. If the full operative note is dictated or is not directly entered into the electronic
medical record before the patient moves to the next level of care, a brief
postoperative progress note should be entered in the electronic medical record. This
note should contain the surgical findings and operative procedure, estimated blood
loss, specimens removed (if applicable), postoperative diagnosis, and names of
primary surgeon and assistants.
e. Operative reports directly entered or dictated by a GME trainee must be
countersigned by the responsible staff surgeon. Operative reports should be
electronically edited and/or signed as soon as possible after the procedure.


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5. Anesthesia Notes
a. Pre-anesthesia note
A pre-anesthesia evaluation must be performed within 48 hours prior to surgery or a
procedure requiring anesthesia services by an individual qualified to administer
anesthesia. The evaluation shall include a notation of anesthesia risk; anesthesia,
drug, and allergy history; any potential anesthesia problems identified; and, the
patient's condition prior to induction of anesthesia.
b. Post-anesthesia note
A post-anesthesia evaluation is completed and documented by an individual qualified
to administer anesthesia within 48 hours after surgery or a procedure requiring
anesthesia services. Documentation shall include the patient's cardiopulmonary
status; level of consciousness; any follow up care and/or observations; and, any
complications occurring during post-anesthesia recovery.

6. Consultation/Consult Follow-up Notes
a. Consultation notes should contain a written opinion by the consultant that reflects,
when appropriate, an actual examination of the patient and the patient's medical
record. Consultation notes written by GME trainees should be countersigned, dated
and timed by medical staff consultants. (Refer to Medical Staff Bylaws.)

7. Behavior Management Procedures
a. The need for use of behavior management procedures, such as restraint or seclusion,
must be documented in the medical record. Clinicians must document in detail that
the use of procedures is warranted and that patients are protected during the
procedures. Documentation shall also include the length of treatment and evidence of
staff efforts to maintain a patient's personal needs while in restraint or seclusion.

8. Discharge summary
a. Discharge Summaries shall be directly entered into the electronic medical record or
dictated within 48 hours upon discharge. If dictated, transcription is completed within
72 hours, and note is edited and/or signed by the attending physician within 72 hours
of availability. The discharge summary shall contain:
i. reason for hospitalization,
ii. significant findings,
iii. procedures performed and treatment rendered,
iv. condition of the patient and disposition on discharge, and
v. any specific instructions given to the patient and/or family.
b. The final diagnoses must be recorded in full, without abbreviations. Suggestions as to
follow up care should be made as specific as possible.

9. Pended Notes/Incomplete Notes
All notes entered into the electronic medical record that are pended with a status of
“incomplete” must be completed and signed within 30 days of discharge or the note will be
deleted.

10. Coding Queries
Coding and CDI queries sent to HealthLink InBasket should be completed within
72 hours of availability. A query facilitates complete and comprehensive reporting of
diagnoses and procedures.


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11. Patient Care Orders (Refer to Policy 8.16)
a. Computerized provider order entry (CPOE) is the preferred method for submitting
orders.
b. Use of secure or unsecured text messaging for patient care orders is not acceptable.

B. Ambulatory Surgery Patients
A complete medical record shall include, so far as applicable: identification data (when not
obtainable, the reason must be entered); medical history; relevant physical examination;
diagnostic and therapeutic orders; evidence of appropriate informed consent (when not
obtainable, the reason must be entered); clinical observations, including results of therapy; reports
of procedures, tests and the results; and on release the plans for further care.

1. History and Physical (H&P)
a. A history and physical examination shall be recorded within 24 hours after the patient
physically arrives for admission/registration, but prior to surgery or a procedure
requiring anesthesia.
b. H & P shall be recorded by a member of the attending staff, Graduate Medical
Education (GME) trainee, or physician assistant or nurse practitioner under the
supervision of the attending staff. Under special circumstances, such as when
emergency measures must be taken immediately, a brief admission note may be
recorded pending completion of the history and physical examination.
c. The minimum content of the H&P includes:
i. Chief complaint
ii. History of present illness
iii. Relevant past history, allergies and medications
iv. Relevant physical examination, to include heart/lung evaluation for pre-
surgical patients
v. Psychological and social assessment, if appropriate
vi. Treatment plan
d. If an H&P is recorded by a physician assistant, nurse practitioner, or a GME trainee,
the attending physician is required to countersign each record within 24 hours after
the patient physically arrives for admission/registration, but prior to surgery or a
procedure requiring anesthesia, and document either approval of the H&P or
disagreement, with any appropriate revision(s).
e. The H&P may be performed up to 30 days prior to admission/registration, but prior
to surgery or a procedure requiring anesthesia. An update of the patient's condition
after examination, with any changes noted, must be documented in the record within
24 hours after admission/registration but prior to surgery or a procedure requiring
anesthesia.
f. An H&P performed by a patient's local physician/NP/PA (non-UW Health) within 30
days prior to patient physical arrival for admission/registration, but prior to surgery or
a procedure requiring anesthesia, may be used provided the attending physician
indicates review, examines the patient, makes any necessary additions, and signs,
dates and times the note within 24 hours after the patient physically arrives for
admission/registration, but prior to surgery or a procedure requiring anesthesia.
g. Any H&P completed greater than 30 days prior to admission/registration, but prior to
surgery or a procedure requiring anesthesia services cannot be updated and a new
H&P must be completed.



Page 7 of 9

2. Progress Notes
a. Progress Notes should give a pertinent chronological report of the patient's course in
the hospital and reflect any change in condition and the results of treatment.
b. All notes should be dated (including year), with the time of day noted, and signed by
the writer who will identify his/her position.
c. A progress note for each patient must be entered daily by the attending physician. A
GME trainee or medical student note which clearly states the presence of the
attending physician and is countersigned, dated and timed by the attending physician
satisfies this requirement. In addition, the supervision of GME trainees and medical
students must be verified either by mention in the daily attending physician note or
by the attending physician's co-signature of the progress notes entered by GME
trainees and medical students.

3. Informed Consent
a. Informed consent of the patient must be obtained and documented as required by
Administrative Policy 4.17-Informed Consent.

4. Operative Notes
a. An operative note is required for all operative and high risk procedures.
b. The responsible physician should record and authenticate a pre-operative diagnosis
prior to operating.
c. Operative reports should be directly entered into the electronic medical record or
dictated after surgery before the end of the next business day. The report will contain:
i. description of the procedure,
ii. findings,
iii. specimen(s) removed or altered (if applicable),
iv. postoperative diagnosis,
v. estimated blood loss (if applicable), and
vi. name of the primary surgeon and any assistants.
A deficiency notice will appear in the attending surgeon’s Inbasket folder if
the full operative note is not completed by the end of the next business day.
d. If the full operative note is dictated or is not directly entered into the electronic
medical record before the patient moves to the next level of care, a brief
postoperative progress should be entered directly into the electronic medical record.
This note should contain the surgical findings and operative procedure, estimated
blood loss, specimens removed (if applicable), postoperative diagnosis, and names of
primary surgeon and assistants.
e. Operative reports directly entered or dictated by a GME trainee must be
countersigned by the responsible staff surgeon. Operative reports should be
electronically edited and/or signed as soon as possible after the procedure.

5. Anesthesia Notes
a. Pre-anesthesia note
A pre-anesthesia evaluation must be performed within 48 hours prior to surgery or a
procedure requiring anesthesia services by an individual qualified to administer
anesthesia. The evaluation shall include a notation of anesthesia risk; anesthesia,
drug, and allergy history; any potential anesthesia problems identified; and, the
patient's condition prior to induction of anesthesia.
b. Post-anesthesia note
A post-anesthesia evaluation is completed and documented by an individual qualified
to administer anesthesia within 48 hours after surgery or a procedure requiring

Page 8 of 9

anesthesia services. Documentation shall include the patient's cardiopulmonary
status; level of consciousness; any follow up care and/or observations; and, any
complications occurring during post-anesthesia recovery.

6. Patient Care Orders (Refer to Policy 8.16)
a. Computerized provider order entry (CPOE) is the preferred method for submitting
orders.
b. Use of secure or unsecured text messaging for patient care orders is not acceptable.

C. Outpatients
A complete medical record shall include, so far as applicable: identification data (when not
obtainable, the reason must be entered); medical history; relevant physical examination;
diagnostic and therapeutic orders; evidence of appropriate informed consent (when not
obtainable, the reason must be entered); clinical observations, including results of therapy; reports
of procedures, tests and the results; immunization status; a problem list; and medication list.

1. Outpatient visits must be documented in the primary UW Health medical record. Outpatient
clinic visits will be directly entered, dictated or written within 48 hours (weekends
excluded) of the visit, and should be edited and/or signed within 72 hours of availability.

2. The minimum requirements for documentation are:
a. reason for the visit
b. current findings
c. assessment or plan
d. current status of medications
e. allergies
f. name of the clinician

3. Each item must be as detailed as is appropriate for the nature of the visit.

4. If the outpatient visit will involve a surgery or procedure that requires anesthesia, follow
the H&P requirements outlined in the Ambulatory Surgery Patients section.

5. Summary List
a. A summary list consisting of significant diagnoses, procedures, medications and
allergies must be maintained for each patient.

6. Informed Consent
a. Informed consent of the patient must be obtained and documented as required by
Administrative Policy 4.17-Informed Consent.

7. Patient Care Orders (Refer to Policy 8.16)
a. Computerized provider order entry (CPOE) is the preferred method for submitting
orders.
b. Use of secure or unsecured text messaging for patient care orders is not acceptable.


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V. COORDINATION

Sr. Management Sponsor: SVP, Chief Information Officer
Author: Director, Health Information Management
Reviewers: Medical Record Committee

Approval Committee(s): UW Health Administrative Policy & Procedure Committee



SIGNED BY

Elizabeth Bolt
UW Health Chief Administrative Officer