Health Information Management

• Contact Information
• Dictation/Adult Ordering
• Medical Records Policy
• Clinical Documentation Integrity Program

Contact Information

Mary Garcia, Director, 325-670-6516
Dusty Muller, Supervisor, 325-670-2496
Martha Davis, Supervisor, 325-670-2247
Eunise Diaz, Data Specialist, 325-670-6316
Medical Records Incomplete Chart Room, 325-670-2901

Please e-mail the Medical Records director with a courtesy copy to the data specialist at least a week prior to being out of town for more than a few days so records will not be counted incomplete in your absence. This does not exempt you from completing all available records prior to your departure.

Dictation/Adult Ordering

North Campus

At the voice prompt:

• Step 1 Enter your User ID number followed by the # sign
• Step 2 Enter the Work Type (below) followed by the # sign
• Step 3 Enter the Patient Visit Number followed by the # sign
• Step 4 Press 2 to begin dictation. Please state your name, the type of report, and patient’s first and last name.
  • Note 1: Please separate reports by pressing 5
  • Note 2: To insert Dictation, please tell the transcriptionist to insert at a specific point.
• Step 5 Press 5 to end dictation and start next job, begin at step 2
• Press 9 to disconnect and play job number.

If a STAT report is needed, please contact an HIM Contact listed above.

Work Type Numbers

1. History and Physical
2. Consultation
3. Operative Report
4. Endoscopy
5. Heart Catheterization
6. Discharge Summary
7. Bronchoscopy
8. Procedure Note
9. EEG
10. Heart Failure H&P
11. Progress Note
12. ER/Trauma Center Note
13. Cardiac Rehab H&P
15. NI Stress Test
16. NI Test Results

South Campus

To Telephone Dictate:

1. Dial into AQuity dictation system:
   1. From inside the hospital, Dial: 1190
   2. From outside the hospital, Dial:428-1190 or Main dictation#: 1-844-473-9224 or Backup dictation #: 1-877-411-8178
2. Enter your Physician ID then [#] (pound) key
3. Enter the Work Type, then [#] key
4. Enter Patient Account Number, then [#] key
5. Press 2 to dictate
6. Press 8 to complete your report (and begin another)
7. Press 5 to complete your report (and exit)

• Work Type Numbers

1. History and Physical
2. Consultation
3. Operative Note
4. Endoscopy
5. Heart Catheterization Note
6. Discharge Summary/Short Stay
7. Bronchoscopy
8. Procedure Note
9. EEG
10. Heart Failure Clinic
11. Progress Note
12. ER/Trauma Center Note
13. Clinic
15. Stress Test
16. NI Cardiovascular Test Results

Medical Records Policy

View Medical Staff Policy MS2, Medical Records

Clinical Documentation Integrity Program

The goal of Hendrick Medical Center’s Clinical Documentation Integrity (CDI) Program is to clarify ambiguous, conflicting or incomplete documentation. Our CDI Program helps ensure that physician documentation accurately paints the clinical picture of the patient, thus reflecting the integrity of the clinical, quality and safety outcomes.

Clinical Documentation Coordinator

The clinical documentation coordinator works to facilitate the overall quality and completeness of clinical documentation to accurately represent the severity, acuity and risk of mortality profile of the patient. Focused communication with the treating clinical professionals (i.e. queries) will be utilized to obtain improvements in documentation.

Our CDI coordinators are experienced registered nurses with strong clinical backgrounds, who are proficient in ICD-10 terminology. They review clinical documents and provide feedback to physicians and mid-levels to fill the gaps in documentation. Questions might include clarification in coding, quality measures and overall care management of a patient. Additionally, CDI coordinators act as a bridge between the providers and certified coders to close any documentation gaps.

Why query?

A query is a routine communication and education tool drafted by a CDI coordinator or a certified coder after review of the medical record. Concurrent queries are initiated “real time” during the course of the patient encounter or hospitalization at the time the documentation is naturally done.

The query provides:

• Accurate profiling ((risk of mortality (ROM), length of stay (LOS) and severity of illness (SOI)
• Improved specificity of coding data, as evidenced by accurate capture of co-morbidities (CC) and major co-morbidities (MCC)
• Support documentation requirements needed for current accepted professional coding practices and convention following ICD-10 Guidelines
• Accurate reimbursement for services rendered, complexity of care and resource utilization

Provider benefits:

• Improved patient outcomes and patient satisfaction
• Better data for creation of benchmark physician profiles, physician quality scores and how coding defines the expected LOS, core measures, hospital-acquired conditions and patient safety indicators
• Better recognition of patient co-morbidities thereby accurate capture of a patient’s SOI, ROM and CMI
• Improved operational efficiency in healthcare organizations
• Decreased risk of conversion to observation stay
• Performance metrics-utilization of SOI and ROM
• Complete and consistent records for patient care and data collection
• Support CMC Value Base Purchasing Program

Hospital benefits:

• Documentation is necessary for complying with quality measures
• Quality information supports care management and making sure protocols are followed
• Documentation supports coding, which is the basis of correct revenue and reimbursement

Helpful Tips:

From the Physician Advisor

• Make sure accurate diagnoses are coded to the appropriate level
• Include daily appropriate documentation when writing each day’s note, including query responses
• Upgrade daily or add any new diagnoses to the problem list at the caduceus symbol in Apollo

The discharge summary will be the judge of what physicians will be paid. It’s not about volume, it’s about levels of service.

CDI Team:

Mariela Agosto-Rivera, MD
Clinical Documentation
Physician Advisor
325-670-6568
magosto@hendrickhealth.org

Mary Garcia, RHIA
Director, Health Information Management
325-670-6516
mbgarcia@hendrickhealth.org

Tess Tolentino, RN, BSN, PCCN, CCDS
Clinical Documentation
Program Manager
325-670-6511
ttolentino@hendrickhealth.org

Lorna Taylor, RN, BSN, CAPA, BBA
Clinical Documentation Coordinator
325-670-6504
ltaylor@hendrickhealth.org

Whitney Chandler
Clinical Documentation Coordinator
325-670-6572
wchandler@hendrickhealth.org

Rebecca Horn, RN, BSN
Clinical Documentation Coordinator
325-670-6571
rjhorn@hendrickhealth.org

Krystal Irwin, RN, BSN
Clinical Documentation Coordinator
325-670-6502
kirwin@hendrickhealth.org

Wendy Valdez, RN, BSN
Clinical Documentation Coordinator
325-670-6507
wvaldez@hendrickhealth.org

Robin Allen, RN, BSN
Clinical Documentation Coordinator
Hendrick Medical Center Brownwood
325-649-3409
rallen@hendrickhealth.org

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