I'm interested in hearing how other facilities are handling it when a surgical consent comes down with a discharged record, but it has not been signed by the physician? Is this something your chart analysts review for after discharge? Or do you have a concurrent process in place (i.e. O.R. catches it)? Some other process? And do you flag these consents for physician signature after the fact? Thank you.

Darlene Lilly
HIM Director
Augusta Medical Center


  • edited May 2016
    We do not flag or review for completion at anytime in HIS.
  • edited May 2016
    We do review for unsigned consents after discharge and tag for physician
    signature. OR is supposed to catch these prior to the procedure but by
    us doing this additional monitoring, we can track when this step might
    start falling through the cracks and notify the OR Director.

    Nancy Moran, RHIT
    Medical Records Manager
    Lodi Memorial Hospital
    (209) 339-7531 - Phone
    (209) 368-3745 - Fax

    "Teamwork is a lot of people doing what I say."
  • edited May 2016
    Our OR staff won't let the physician proceed into the OR if the Consents,
    HP and Surgical Site check list aren't completed.
    HIM Does not monitor consents for missing signatures.

    Kristen Meredith,RHIA
    Director, Health Information Management
    Good Samaritan Hospital
    (410) 532-3889

    "Moran, Nancy"
  • edited May 2016
    The HIM department monitors compliance with regards to consent completion. When a consent form is incomplete we generate an incident report to our Patient Care Assessment department.
  • edited May 2016
    We do not flag either. We review these as part of the quality review and
    track compliance.
    Pam Andry
    Director, HIM
    Orange Regional Med. Center
    Middletown, NY
  • edited May 2016
    While HIM is involved in the discussion, ultimately, it's the Risk Manager and our Legal Department that oversee this process.
  • edited May 2016

    Here it is the clinical department with the appropriate medical staff committee. I believe it then gets legal review. HIM is not involved in consent content decisions other than to perhaps make a recommendation or two.

    The issue that is arising here with consents is photography done without a specific photography/video recording consent. Our consents to not have a blanket (..."may include photography or other recording by your provider") statement, which we need to consider. Those kinds of content issues may identified only by what HIM Department or Privacy Officer is seeing as issues.

    My two cents. :)

    Marianne Dailey, BS, RHIT, CHP, CPHQ
    Director HIM & Privacy Officer
    Central Peninsula Hospital
    Soldotna, Alaska 99669
    (907) 714-4563
  • edited May 2016
    Thank you for your input. I appreciate it.

    Our Conditions of Admission and Treatment includes a paragraph on photos and filming. This is information is included in a policy we have on photography, filming and recording in the hospital.
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