Medical Staff House Staff Orientation Manual - Montefiore Medical ...

Medical Information
If medical information must be sent to or obtained from another health care institution, call ext.
4921 at Moses or 2748 at Weiler for assistance, from Monday to Friday 8:30am to 5:00pm. Call
ext. 5315 at Moses or ext. 8109 at Weiler on weekends and off-hours.
SECURITY AND CONFIDENTIALITY
• Patient Information is confidential and may be disclosed only to the extent authorized or
necessary for patient care
• Refrain from discussing patient information in elevators and other public places.
• Do not share passwords or sign-ons
• Medical records are not to leave MMC's premises
• Medical records must be returned to the file-room no later than 48 hours after being signed
out, except when being used for direct patient care
• Medical records required for review purposes should be reviewed in the HIM department
COMPLETION OF MEDICAL RECORDS
Documentation requirements for the medical record are governed by the JCAHO standards, the
NYS Department of Health regulations, HCFA Medicare Conditions of Participation, and MMC
Medical Staff Bylaws. These regulations/standards provide the requirements of a complete
medical record. Medical records of discharged patients must be completed within 30 days of
discharge.
Each clinical department determines its own guidelines regarding the responsibilities of
house officers for record completion. The following represents general guidelines for
documentation in the medical record and provides some guidelines to assist in reducing the
number of incomplete records.
Entries
• Time and date all entries. Include day, month, year as well as time of day, am vs. pm.
• All entries must be permanent and written in blue or black ink. Do not use a pencil or felt tip
marker.
• Make good entries the first time. Entries should be accurate, timely, objective, specific,
concise, consistent, comprehensive, logical, legible, clear, descriptive and reflective of the
patient's condition and response to treatment.
• Legality: The medical record is a legal document. It should not be used to document
complaints against other staff members or departments.
• Authentication: Sign every entry including addenda. Print your name and professional
designation (PGY 1, MD, PA etc.) with your signature. Never make or sign an entry for
someone else or have another make or sign an entry for you.
• Patient Identification: In the absence of an addressoplate ensure that the patient's name and
medical record number is on every page where there is patient information.
History and Physical
Complete an H&P including a pap smear and breast exam on every female patient 21 years and
over, within 24 hours of admission.
Physician Orders
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