OPERATING PROCEDURE Florida State Hospital
NO. 151-9 Chattahoochee, Florida
October 18, 2010March 20, 2008
Medical Documentation/Records
FILING/THINNING -- MASTER RECORD
1. Purpose:
a. To facilitate retrieval and compilation of treatment information into a clinical record.
b. To provide uniformity of record format throughout Florida State Hospital (FSH).
2. Scope: This operating procedure applies to all resident medical records and the materials contained within those records.
3. Training Requirements: Staff that create, maintain, file, and review the master record will be trained on this operating procedure upon hire into the position during Worksite Education and by their supervisor each time the operating procedure is revised.
4. Responsibility:The Unit Health Information Specialist is assigned the responsibility for creating a master record at the time of admission, periodic review and update of information in the master record, and assuring that filing into the master record is correct.
5. References:
a. Florida State Hospital Operating Procedure (FSHOP) 151-8, Completion/Changes/ Corrections of Face Sheet and Addendum to Face Sheet.
b. FSH Manual 130-1, Service Implementation Record Manual.
6. Procedure:
NOTE:Only forms approved by the Medical Record Committee may be placed in the master record.
a. Master Record:
(1) The unit health information specialist/designee will prepare,prepare copy, distribute, file and mail admission documents within three (3) working days of admission. These documents will be filed in the master record.
(2) A confidentiality sticker and volume sticker will be placed on the outside of the master record.
This operating procedure supersedes: Operating Procedure 151-9, dated February 14March 20, 2008
Office of Primary Responsibility: Health Information Manager
Distribution: FSH Computer Network Users
Operating Procedure 151-9 March 20, 2008
October 18, 2010
(3) The master record will be labeled with the resident’s name (as it appears on the commitment order or voluntary admission form) and medical record number in at least a 12 point typed font.
b. Filing Order:
NOTE:Unit 31 will have the same filing order for both the ward chart and the master record. All material from each admission will be placed in one section of the record folder and the section divider will be labeled as to admission and discharge dates to Unit 31. Material will be filed in the order it is taken from the ward chart.
(1) The master record is divided into six (6) sections separated by dividers built into the record folder.
(2) The filing order of each section is printed on cardstock paper and filed at the top of each section.
(3) The master record will contain originals of all forms/reports done at FSH. Copies of records will not be maintained by staff members/departments.
(4) All documents filed in the master record will contain the resident’s name and medical record number (on the front and back of two-sided documents).
(5) Material in each section is filed in the order listed below. The FSH/Children and Families (CF)/Department of Health (DH) form number is included with the titles of materials. Hospital-wide forms are shown in bold type (and capital letters on the Filing Order).
SECTION 1--CORRESPONDENCE:
Materials in this section are filed in date order, using the date written--not date received. Below are examples of materials to be filed in this section.
Admission and Movement Record (CF 281)Admission and Movement Record (CF 281)
Aftercare Appointment
Authorization to Release Information (attached to theletter requesting the information) NOTE: Form3044 done at the Hospital is filed in the Legal Section
Consent to Transfer (Interstate) (12)
Fee Maintenance Information (CF 280) Fee Maintenance Information (CF 280)
Insurance Forms
Invitation/Response to Service Team Meeting (241)
Leave of Absence Authorization/Questionnaire (200) {after resident returnsto Hospital}
Letters/Memos
Medical Record Correction/Amendment Form (425) NOTE: If approved attach to original document which was corrected or amended. If denied file in Correspondence
Notice of Legal Action/Supplementary Information (17)
Notice of Right to Apply for Discharge (434)
Pre-Admission Form (Obstetrics) (61)
Report of Contact (582)
Resident’s Access to Own Record (299)
Resident Transfer Information (201){copies of medical and psychiatric report, social work notes may be attached}
Social Security Forms
Social Service Questionnaire (145) {Forensic}
TMH/CRMC Admission Form
DIVIDER SHEET (Medicare/Medicaid Units)
Medicare/Medicaid Certification/OtherMedicare/ MedicaidForms/Letters
Utilization Review Forms
SECTION 2--LEGAL:
DISCHARGED RECORD:
Notice of Discharge (3038) {also use for Discharges while on Elopement, AWOL,and Escape}
Application for Discharge (CF-MH 3051b) (if application results in discharge)
Discharge Receipt (487)
Medical Recommendations at Release (465)
Leave of Absence Authorization/Questionnaire (200) {if discharged while onLOA}
Report of Elopement/Escape (608) {if discharged while on Unauthorized Absence}
Elopement Risk Assessment Protocol (256) {if discharged while on elopement}
Discharge Summary Form--Civil (7001)--use for Civil residents and in Forensic for NGI’s and community placement
Discharge Summary Form--Civil--Resident Information Transfer Checklist (7001A)
Authorization to Discharge Prior to Benefits Acquisitions (239)
Physician to Physician Transfer Form (CF-MH 7002) (if done at time of discharge from FSH)
Discharge/Separation LOA Summary for 916 Commitments (333 465) {Forensic}--use for ITP’s returning to jail
Transition/Transfer Plan (56) (Filed here only when used as a Discharge Summary on a 394 resident being transferred to another State Hospital.)
Continue as described under ACTIVE RECORD below.
DECEASED RECORD:
MORTALITY SECTION DIVIDER:
Certificate of Death (DH Form 512)
Death Slip (592)
Physician's Report of Contact to Relatives at Time of Resident's Death (282)
Report of Contact (582) (containing notification to sheriff, district health officer, Medical Examiner, family regarding funeral arrangements, etc.)
Statement of Death (96)
Consent for Autopsy
Release to Funeral Home/Medical Examiner (370)
Provisional Gross Pathological Diagnosis
Autopsy Report
Expiration Note {written on Medical/Psychiatric Progress Note when death pronounced}
Death Summary (20)
Interval Death Note (Unit 31)
Psychiatric Death Summary
LEGAL SECTION DIVIDER:
Continue as described under ACTIVE RECORD below.
ACTIVE RECORD:
Report of Elopement/Escape (608) {move to Correspondence section upon return from unauthorized absence}
Face Sheet (2006)
Addendum to Face Sheet (6)
Previous Admissions (36)
Resident Movement (printout from CMHC)
Copies of Master Index Card (only if records of previous admissions have been destroyed)
Prearranged Funeral Contract/Special Instructions
Do Not Resuscitate Order (DH Form 1896)
Approval Form for EnteralEnternal Feedings (581)
Advance Directive Forms (632)
Hearing Status Notification (discard when order is received)
Final Order for Continued Involuntary Hospitalization/Application for Transfer to Voluntary Status (9)/Notice of Right to Transfer from Involuntary Status to Voluntary Status--Application for Transfer to Voluntary Status--Notice of Transfer to Voluntary Status (628)
Court Orders Dropping Charges
Commitment Order; Certification of Patient’s Competence to Provide Express and Informed Consent (CF-MH 3104)--(Voluntary residents only)
Order for Restoration of Competency
Order Adjudging Incompetency
Florida Local Advocacy Counsel (FLAC) File Review
Series 3000 Legal Forms (in numerical order) (Petition for Involuntary Placement {3032}, Petition Requesting Authorization for Continued Involuntary Placement {3035}, Notice of Right to Petition for Writ of Habeas Corpus or for Redress of Grievances {3036}, General Authorization for Treatment Except Psychotropic Medications {3042}, Authorization for Release of Information {3044}, Notice of Patient’s Admission {3045}, Application for and Notice of Transfer to Another Facility {3046}, Restriction of Communication or Visitors {3049}, Withdrawal of Application for Discharge {CF-MH 3051Bb}, Application for Discharge {CF-MH 3051bB}--if application does not result in discharge)
Orders Pertaining to Guardianship (if public guardian, instructions will be attached)
Guardianship Reports/Hearings
Consents (in date order) {Consent Form for the Confidential Human Immunodeficiency Virus (HIV) Test (DH1818); Consent for DentalTreatment or Surgery (CF 1314, 1315, or 1316); Informed Consent for Operative Procedures/Competency Certification/Authorization for Emergency Surgical/Non-Psychiatric Medical Treatment/Procedure (630); Informed Consent for Minor Operative Procedures (577); Oral Contraceptive Consent Form (587); Intrauterine Device Consent Form (584)}; Court Consent for Treatment/Surgery; Approval for Elective Medical/Dental Procedures (319); Agreement to Participate in Medication Management Program--Phase Three (286); Determination of Competency for Phase Three of the Medication Management Program (332)}
Petition for Writ of Habeas Corpus (438)
Legal Papers (Divorce, Will, Birth Certificate)
Resident Orientation Checklist (470) {after discharge}
Receipt of Management and Protection of Personal Health Information Policy (432)
Inventory/Receipt of Resident's Tangible Personal Property (415)
Accountability of Resident's Personal Property Prior to Discharge (418)
Disposition of Resident's Broken or Worn-out Property (421)
Transfer of Abandoned Non-Tangible Resident's Personal Property (419)
Notice of Hearings, Motions, Petitions and other legal documents not indicated above (file in date order – not by like forms)
Visitor's CardRecord (60)/Approved Visitors’ List (8) (Forensic)
DIVIDER SHEET
BA Forms from Other Facilities (prior toadmission toFSH)
PSYCHOTROPIC MEDS:
Medical/Psychiatric Progress Notes (64)
Monthly Medical Summary (63)
Monthly Medical Summary--Addendum (289)
Psychiatric Progress Note (220)
Annual Comprehensive Admission & Annual Psychiatric Evaluation (259) {Annual}
Comprehensive Psychiatric Admission or Annual Comprehensive Psychiatric Evaluation--Addendum (260) {Annual}
Monitoring of Side Effects Scale (MOSES) (181)
Brief Mental Status Examination (360)
Medication History (604)
Abnormal Involuntary Movement Scale (AIMS) (77)
Psychotropic Medication Exception Request (CF 1582)
Informed Consent for Psychotropic Medication(s) (CF Form 1630)/Court Orders
Psychotropic Medication Information Sheets (attach to Consent Form [CF Form 1630] or Court Order)
Report of Contact (582)/Letters Related to Psychotropic Medications (with certified receipts attached)
Notice of Hearings, Motions and Petitions Related to Psychotropic Medications (file in date order not by like forms)
SECTION 3--DATA BASE:
Competency Evaluation Administration Record (346)
Clinical Summaries/Competency Evaluations (NOTE: File all Summaries in date order, most recent on top)
Review BoardSummary Sheet (566)
Review Board RoutingSheet (567)
Barriers Checklist (417)
Discharge Challenges Checklist—Civil Commitment (143)
Psychiatric History (24/24A) (Deleted 9/30/07)
NOTE:Updates are filedabove the history.
Baker Act Summaries (277 & 278)
Guardian Advocate Summaries
Adult Health History/Family Planning Services (586)
Tracking Sheet for Resident Refusal of Health Care Services (223)
Medical History/Physical Examination/Neurological Examination (1)
Psychological Reports
Functional Assessment Rating Scale (217)
Comprehensive Psychosocial Assessment (11/11A)
Substance Use/Abuse Screen (83)
Discharge Summary Form-- (7001) (whenresident does not leave the Hospital)
Discharge Summary Form--Civil--Resident Information Transfer Checklist (7001A) (whenresident does not leave the Hospital)
Physician to Physician Transfer Form (CF-MH 7002) (when resident does not leave the Hospital )
Dental Card (after discharge)
Dental Record (CF-MH 2010/2010A)
Blood Transfusion Record (76) {Unit 31}
Lab Reports (in date order – not by like forms)
PAP Smear/Pathological Reports
X-Ray Requisition/Report (403)
CAT Scan/Ultrasounds
Mammogram
Electrocardiograph Report
Electroencephalogram
Medication Education Assessment (43)
Nursing Assessment (31)/Unit 31 Nursing Assessment (349) {Unit 31} (in date order)
Elopement Risk Assessment Protocol (256) (upon return from elopement)
Readiness Profile/Program Status (208)
Assessment of Pressure Ulcer Potential (121)
Rehabilitation Therapy Interest and Skills Assessment (21) {Annual}
Rehabilitation Therapy and Skills Assessment (428) {Unit 14} {Annual}
Medical Nutrition Therapy Assessment (170)
Medical Nutrition Therapy Progress Note (171)
Medical Nutrition Therapy Medication/Nutrient Interactions (176)
Dental Card (after discharge)
Dental Record (CF-MH 2010/2010A)
Blood Transfusion Record (76) {Unit 31}
DIVIDER SHEET--DISCHARGED RECORD: (Admission Information)
(pulledPulled from Admission/Discharge section of ward chart into Volume 1, Master Record)
Admission Comprehensive Admission & Annual Admission Psychiatric Evaluation (259)
Admission Comprehensive Psychiatric Admission or Annual Comprehensive Psychiatric Evaluation--Addendum (Admission only) (260)
Psychiatric Evaluation and Admission Note (28) (Deleted 9/30/07)
Admission Assessment & Comprehensive Psychiatric Evaluation – Unit 14/15 (28A) (Deleted 9/30/07)
Admission Medical History/Physical Examination/Neurological Examination (1)
Admission Abnormal Involuntary Movement Scale (AIMS) (77)
Admission/Baseline Monitoring of Side Effects Scale (MOSES) (181)
Brief Mental Status Examination (360) (if done on admission)
Physician's Orders--Admissions Physical (94)/Physician's Orders (any completed at the time of admission) (150)
Admission Lab and X-Ray
Admission Progress and Event Note (52)
Admission Medication Education Assessment (43)
Admission Nursing Assessment (31)
Ward Staff Admission Note (32)
Admission Psychosocial Assessment (22)
Admission Substance Use/Abuse Screen (83)
Admission Psychology Admission Assessment Evaluation (269)
Admission Direct Care Assessment (26)
Admission Rehabilitation Therapy Interests and Skills Assessment (21)
Admission Rehabilitation Therapy and Skills Assessment--Unit 14 (428) {Unit 14} `
SECTION 4--TREATMENT:
Ongoing Issues (183)
Temporary Medical/Other Service Needs (185)
Current Diagnoses (207)
Recovery Plan Meeting Minutes (147)
Recovery Plan (54)
Recovery Plan – Units 14/15/27 (54A)
Monthly Recovery Plan Signature Page (148)
Transition/Transfer Plan (56)
Psychiatric Rehabilitation Objective/Component Recommendation Form (353)
Family Planning Service Questionnaire (578) {file behind corresponding page of SIP}
Preferred Environment (511)
Functional Assessment Chart (512)
Resource Assessment Chart (513)
Inferring Personal Criteria (514)
Description of Alternative Environments (515)
Personal Safety Plan Form (325)
Communication Assessment for Hearing Impaired Residents (5)
Clinical Risk Assessment Instrument (65)
Personal Safety Plan (325)
Communication Assessment for Hearing Impaired Residents (5)
Customer/Companion Communication Assessment (DCF Form)
Preference Assessment for Resident with Limited English Proficiency (595)
Preference Assessment for Visually Impaired Residents (596)
Summary for HCR-20 Assessing Risk for Violence Version 2 (263)
High Risk Meeting Minutes Report (156)
FOM Flow Sheet (298) {Civil}
Central Forensic Services Freedom of Movement--Forensic Services (240) {Forensic}
Outpatient Therapy Plan of Treatment, Certification/Recertification (48)
Outpatient Treatment Log (49)
Preferred Environment (511)
Living Environment Alternative Preferences (LEAP) (53)
Functional Assessment Chart (512)
Resource Assessment Chart (513)
Inferring Personal Criteria (514)
Description of Alternative Environments (515)
Physician's Orders (150) *
Physician’s Orders--Monthly/Quarterly Lab (195) *
Physician’s Orders--Admissions Physicals (94) *
Physician’s Diet Orders--Meal, Snacks, Supplements (99) *
Physician’s Orders--Computerized*
Physician’s Restraint Order (236) *
Physician’s Seclusion Order (237) *
Restrictive Procedure Initial Order (162) *
NOTE: Physician’s Orders with an * are filed IN DATE ORDER, do not file by like form.
Non-Psychotropic Medication Exception Request (67) {attach and file with corresponding Physician's Order}
Treatment Orders (10)
NOTE: The following materials are filed below the Treatment Orders IN DATE ORDER,ORDER; do not file by like form:
Consultation/Referral Report (In-House) (29)
Emergency Room Record (50) {attached to consultation of same date}
Information from Outside Facilities and Consultants (while resident is hospitalized at FSH)
Interdisciplinary Case Review
IV Sedation Flow sheet (646) {Unit 31} (attach to Minor Operation Record)
Minor Operation Record (16)
Neurology Screening Clinic Form (372)
Nursing Service Transfer Form (47)
Unit 31 Transfer Summary (238)
Outpatient Medical Record Medical History/Physical Record (Unit 31) (548)
Physician's Discharge/Transfer Summary from Unit 31 (45)
Rehabilitation Referral (157)
Specialty Clinics Request/Report (Non-FSH Providers) (187/187A)
Target Symptom Identification for Psychiatric Clinic (70)
Vocational Service Evaluation Summary and FSH Work Evaluation Unit Tap-Instant Report (staple to consult referring resident to Vocational Services)
SECTION 5--PROGRESS NOTES: