2004 Inpatient Implementation, Psychiatry & Psychology

Admission/Initial Consult Notes (Consultants Only)

ED Consult Dictation for Consultants, Residents, and Midlevel Care Providers

6-7300 Recorder Dept. Codes 36 – all authors are defaulted, and will not need to key this number Work Types/Turnaround Times 62 – Inpatient Admission Workup – 6 hours 64 – Initial Consultation (SMH) – 6 hours 72 – Initial Consultation (RMH) – 6 hours Consultant Admit/Initial Consult Notes Consultants must also handwrite a brief note on the chart to assure vital information is available should the patient require an emergency procedure, preoperative consult, indication of consent, and for immediate communication with other care providers. All inpatient notes other than the above approved consultant notes need to be handwritten (i.e. resident notes, phone call documentation, daily progress notes, follow-up consult notes). Dictation of unapproved inpatient notes will not be transcribed. Office Support Services will call the author to inform them they will need to handwrite the documentation. **NOTE**Inpatient admission/initial consult, ED Consults and ED Procedures are separate, billable events. Be sure to dictate separate DVI dictations to the recorders listed above.

6-7300 Recorder Dept. Codes 36 – all authors are defaulted, and will not need to key this number Work Types/Turnaround Times 70 – ED Consult with Admission or Urgent Follow-up recommended – 30 minutes 71 – ED dismissal recommended with no urgent follow-up – 24 hours ED Consults 6-7300 recorder Consult only documented in Clinical Notes **Be sure to complete the paper billing record **NOTE** ED Consults and ED procedures are separate, billable events. Be sure to dictate separate DVI dictations to the recorders listed above.

Hospital Service Notes on-line	Clinical Notes Service Code (Must DICTATE SERVICE or self-enter accordingly)	Consultant dictations	Resident & mid-level dictations	Clinical Notes Event Type used
PACP: Psychiatric Acute Care Program	State: service name or Code entry: P-ACPI	Admissions WT62 (7 days/wk) Progress WT 63 (7 days/wk) Prelim SUM WT 61 (7 days/wk) Dism SUM WT 66 (7 days/wk)	Self-enter *continue to dictate summaries	Admission: ME Progress: SV Summary: SUM Phone call: MIS
MPP: Medical Psychiatric Program	State: service name or Code entry: P-MPI	Admissions WT62 (7 days/wk) Progress WT 63 (7 days/wk) Prelim SUM WT 61 (7 days/wk) Dism SUM WT 66 (7 days/wk)	Self-enter *continue to dictate summaries	Admission: ME Progress: SV Summary: SUM Phone call: MIS
C/L: Psychiatric Consultation Service (SMH & RMH)	State: service name or Code entry: P-SCI, P-RCI (currently in use for self-entry of consults) Will combine as one on 1/1/05 to become P-CI	Consults: (7 days/wk) .....SMH, WT 64 .....RMH, WT 72	Self-enter	Consultation: CON
MDU: Mood Disorder Unit	State: service name or Code entry: P-MDUI	Admissions WT62 (7 days/wk) Progress WT 63 (7 days/wk) Prelim SUM WT 61 (7 days/wk) Dism SUM WT 66 (7 days/wk)	Self-enter *continue to dictate summaries	Admission: ME Progress: SV Summary: SUM Phone call: MIS
CAP C/L: Child/Adolescent Psychiatry Consultation Service	State: service name or Code entry: CAPCI	Consults: WT 64 (7 days/wk)	Self-enter	Psychiatry Consult
CATP: Child/Adolescent Psychiatry Family Services Inpatient Program	State: service name or Code entry: CAPI	Admissions WT62 (7 days/wk) Progress WT 63 (7 days/wk) Prelim SUM WT 61 (7 days/wk) Dism SUM WT 66 (7 days/wk)	Self-enter *continue to dictate summaries	Admission: ME Progress: SV Summary: SUM Phone call: MIS
Addiction Consulting Service	State: service name or Code entry: P-ADCI		Self-enter	Consultation: CON
ED: Emergency Department	State: service name Or Code entry: CAP-ED: Child & Adole –Emergency P-ED: Adult – Emergency	(7 days/wk) ED consult w/admission or urgent follow-up WT 70 ED consult dismissal WT 71	DICTATE (7 days/wk) ED consult w/admission or urgent follow-up WT 70 ED consult dismissal WT 71	Consultation: CON Staff Consultant may do CON or SUP

Guidelines for Hospital Note Dictation

1. The Hospital Practice and Clinical Practice Committees have approved consultant admission, initial consult, and initial observation notes for dictation. Consultants will be able to dictate electronic initial consultation and hospital admission notes 24 hours a day, seven days a week, with transcription expected to be completed within 6 hours. (A brief hand-written note on the hospital yellow sheets is still required to assure vital information is available should the patient require an emergency procedure, preoperative consult, indication of consent, and for immediate communication with other care providers.)
2. Consultants may continue to dictate weekday progress notes, but these will migrate to the electronic record. We are still negotiating on weekend progress notes and hope to have transcription support for these soon...but, for the moment, these still need to be hand-written.
3. Residents will not yet be able to dictate hospital admission or progress notes, but may self-enter these notes in the electronic record, pulling forward transcribed sections of ED notes if desired. (Residents are already self-entering consultation notes.) Printing on the yellow sheets will no longer be necessary.
4. Notes will be viewed electronically in Documents Browser or LastWord.