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Policies
Medical Records Policy
EPIC is the new Electronic Medical Record (EMR) software that the Loyola University Health System is currently implementing. Complete patient care documentation is expected. Dictations are to be done on a timely basis: Properly completed admission Notes clearly identifying clinical justification, proposed treatment plan, and if applicable, reason for transfer to LUMC or for patient re-admission within seven days of prior discharge from any other hospital. History and physical, progress notes, consultations, reports of operation, physicians, etc., must be recorded within a 24-hour period. Discharge progress Note must be completed at the time of discharge, with principle diagnosis clearly identified. All secondary diagnoses and procedures must be recorded. All operative reports must be dictated within 24 hours of surgery, preferably immediately following the procedure. Discharge summary must be dictated within 24 hours after discharge. It is strongly suggested that summaries be dictated at the time of discharge from the phone at the nursing station. All entries into the medical record must be in black or blue ink. Verbal orders are to be signed within 24 hours. All medical students' notes and orders need to be countersigned by the resident or attending physician within 24 hours. The records must be completed within 72 hrs of discharge All signatures must be accompanied by legible printed name and pager number. Failure to complete charts within 30 days will result in suspension of clinical privileges until charts are completed. For additional information, please contact: |
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