/policies/,/policies/administrative/,/policies/administrative/uwmf/,/policies/administrative/uwmf/uwmf-wide/,/policies/administrative/uwmf/uwmf-wide/clinic-operations/,/policies/administrative/uwmf/uwmf-wide/clinic-operations/health-link/,

/policies/administrative/uwmf/uwmf-wide/clinic-operations/health-link/101053.policy

201410297

page

100

UWMF,

Policies,Administrative,UWMF,UWMF-wide,Clinic Operations,Health Link

Charts Completion and Co-Sign (101.053)

Charts Completion and Co-Sign (101.053) - Policies, Administrative, UWMF, UWMF-wide, Clinic Operations, Health Link

101.053

1
UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
POLICY

TITLE: CHART COMPLETIONAND CO-SIGN

Effective Date: September, 2005 Approval: See Authorization
Supersedes Policy: Past Due/Incomplete Chart Policy Contact: See Author

Reviewed
Revised
10/10/06
Revised
12/12/11
Revised
6/19/13

Revised
10/30/08
10/1/2012
1/4/13


PURPOSE: To provide guidelines for timely co-sign and required documentation of out-patient
encounters.

DEFINITION: Documentation of all interactions with patients, whether in person or via
telephone or electronic messaging, must be completed (closed) within 48 hours of the
visit/call/contact.

POLICY:
1. Documentation, using Health Link smart-tools, typing, dictation or a combination of
these methods, will be completed by the encounter provider or appropriate encounter
nursing staff within 48 hours of the visit or telephone/electronic encounter. Providers
with full Health Link functionality who choose to dictate will note this in the Visit
Navigator by typing the system phrase “.dictate” in the Progress Note section only after
they have dictated; this allows the encounter to be closed/billing to occur. ( To increase
consistency and ensure compliance, personal smart phrases that may include “.dict” will
be removed from the system and should not be recreated.)

2. Dictation will be transcribed within 48 hours1 (weekend days excluded) of receipt of
dictation.

Note: UWHC policy states that dictation will be transcribed within 72 hours. UWHC
does not make exceptions for weekends

3. Dictated documentation will be electronically “signed” by the author within 72 hours1,3
(weekend days included) of transcription completion. Providers will pro-actively plan
for time away by notifying the Transcription Manager of planned time away so that
dictation can be transcribed/signed in a timely manner, utilizing charting tools in Health
Link to ensure that documentation is complete before leaving, or plan to access the
system remotely to sign dictation while out of the office.

Note: UWHC policy requests signature within 72 hours of availability. UWHC does not
make exceptions for weekends.

2


4. Encounters should be co-signed as needed and closed within 48 hours (weekend days
excluded) of the visit/call.

5. Medication/ billable orders as well as all verbal orders will be co-signed within 48 hours.


Providers will receive an InBasket notification at 24 hours for visit encounters not yet closed






PROCEDURE:

Action Needed: Timeline: Next steps:
Close Encounter

(Includes these types of
encounters:
Office Visits, Assessment,
Case Management, Group,
Health Education, Intake,
Multi-D Allied Health, Multi-
D Initial, Multi-D Provider,
OB Visit, Off-Site Facility,
PPC-11R, Procedure, Staffing
Note, Therapy, Treatment
Plan, Anticoagulation Therapy,
Referral, Allied Health/Nurse
Visit, Allergy Injection)






Electronically Sign
Transcribed Dictation








48 hours from date of
service



















Expected to sign
dictation 72 hours
(weekend days
included) from
completed
transcription
Encounter Provider receives notification in
Health Link InBasket “Incomplete Chart” folder
1 calendar day (24 hours) after encounter is
opened.
Clinic Manager receives notification of
incomplete charts 7 calendar days after encounter
is opened.
Clinic Manager explores potential reasons for
non-compliance (leave of absence, time off) and
speaks with staff or provider regarding plan for
completion.
Clinic Manager will report unresolved issues to
the designated supervisor(s) of clinical activity
for the site, who at his/her discretion either
intervenes directly with the provider to help
resolve or refers to the Medical Director or
Department’s Chair/Vice-Chair.
Clinic Manager keeps their respective
Director/Assistant VP apprised of outstanding
issues.

Encounter provider receives notification in
InBasket as soon as dictation is transcribed and
awaiting authentication.
The Director of Health Information/Manager may
attach to a provider’s InBasket to verify that
authentication is happening in a timely manner.
Results will be shared with the respective
Manager, or Director/Assistant VP.
Chart audits may be performed randomly by site

3














Co –Signatures and verbal
orders





Manager or Clinical Documentation Services
staff, and/or initiated at any point there is a
concern about documentation being dictated in a
timely manner. Past Schedules may be checked
against patient records in Health Link to ensure
transcription has been completed. Results will be
shared with respective Manager/Director.
Clinic Manager will report unresolved issues to
the designated supervisor(s) of clinical activity
for the site, who at his/her discretion either
intervenes directly with the provider to help
resolve or refers to the Medical Director or
Department’s Chair/Vice-Chair.


Documentation needing a co-signature or verbal
orders needing signature will be signed within 48
hours



WRITTEN BY: Health Link Clinic Operations Workgroup (HLCOW)
(Formerly the EpicCare Policies & Procedures Committee)

REVIEWED BY: UW Health Link Clinic Operations Workgroup
David Kunstman, UWMF Associate Medical Director
Mary Waldo, UWMF Compliance
Ronnie Peterson, RN, MS, Clinical Health Educator
Sandy Schumacher, RHIT, Health Information Director
Dr Richard Welnick, UWMF Ambulatory Medical Director

REFERENCES: Standing Order Policy, Verbal Order Policy,
Protocol Development & Use Policy
UW Health Ambulatory Service Standards – 2010


AUTHORIZATION:


Medical Director Date


2
Medicare requirement
,3
CMS Incident-to rules