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

All physician orders whether written on paper or entered on-line through Physician Order Entry
must be dated and signed. All sub-intern orders must be countersigned within 3 hours. PA
medication orders must be countersigned within 24 hours. PAs and Sub-interns should ensure
that their orders are counter-signed.
Discharge: Write a discharge order or document circumstances surrounding death,
transfer or AMA status of the patient as appropriate.
Discharge Summary
Complete the Discharge Summary form or dictate a discharge summary on the day of discharge
for all cases with a length of stay of 48 hours or more. All sections of the discharge summary
must be filled out or dictated. A Discharge Note is required on stays of less than 48 hours where
no discharge summary is required. Discharge note should include information regarding the
condition of the patient on discharge and instructions to the patient. A discharge note is required
for all patients who die or who leave AMA. A discharge summary is ALWAYS needed for
expiration cases regardless of length of stay.
Operative Report
Complete the Short Operative Note immediately after surgery. Although the attending physician
is ultimately responsible for the dictation of the operative report the task may be assigned to the
1 st assistant on the surgery. Dictation instructions are below.
DICTATING INSTRUCTIONS
*Please spell all names and unusual medical terms.
Montefiore Medical Center uses a digital voice activated system for dictation of Discharge
Summaries and Operative Reports. The system may be accessed from any touch tone telephone.
The same system is in use at both the Moses and Weiler sites. To obtain your personal ID# to
access the system please contact the Medical Record Completion unit.
• Dial Extension 717 in-house or (718) 920 -6755 for Moses and 3458 in-house or 904-3428
for Einstein.
• Enter your 5 digit attending or house staff physician ID
• Enter the 1-digit work type (e.g. 1=OP Report, 2=Discharge Summary)
• Enter the 8-digit Medical Record Number
• Press:
1 to hold, then "2" to resume dictation
2 Dictate
3 Rewind a few words
4 Go to end of Dictation
5 Go to beginning then "8" to listen
6 End Dictation
7 Fast forward a few words
8 Listen
9 Disconnect
To ensure accurate report tracking when dictating multiple reports, press 6 after each dictation
and then enter the 1 -digit work type and 8-digit patient medical record number for the next case.
FORMAT FOR DICTATION
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