Transcript Documenting Dilemma: Where, What, When and How?

Documenting Dilemma: Where,
What, When and How?
IMIA October 7, 2007
Moderator: Jessica Goldhirsch
Boston Medical Center
FOCIS’ History
• Started January of 2004
• By and for professionals responsible for managing
interpreter services in their health care institutions.
• Forum where coordinators meet and share expertise,
concerns, ideas and information
• FOCIS membership has grown to include a chapter
representing North and South Carolina. FOCIS
members would be happy to speak with you about
starting a chapter in your area.
• Contact for FOCIS:
• [email protected]
Why Documentation?
– Create a record in the patient’s chart
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Interpreters are part of the team
Communicate with providers
Liability/risk management
Joint Commission
– Collect data for report writing
• A variety of measurements can be collected reflecting
interpreted sessions or appointments
• Some databases are stand alone (MS Excel) and others are
connected to scheduling systems (IDX) or (electronic medical
record) EMR systems
• Reports can be written for budgeting or staffing purposes or
for regulatory agencies or other purposes
For Summary on
Joint Commission
Visits to Hospitals
See e-mail from Cindy Roat
to NCIHC List-Serve
Monday, July 30, 2007 at 10:47 a.m.
Health Alliance Hospital
A Member of UMASS Memorial
Healthcare
INTERPRETER SERVICES
Mercedes Urrea
Coordinator
978-466-4065
[email protected]
Patient Identification/Label
60 Hospital Road, Leominster, MA 01453-8004
REQUEST FOR
INTERPRETER SERVICES
Inpatient________ Outpatient__________Time of Request:_____________________________
Primary Language: _________________________ Country of Origin: ____________________ Date: ______________
======================================================================================
Provider’s Name: _____________________________________ Location: _____________________________________
Interpreter arrival time: _________ am / pm
Type of Request:  Scheduled
 ASAP
End of session: _________ am / pm
 Phone
 Doctors Office  On call
Subject: _____________________
 Other_________________________
Interpreter’s Name: ___________________________________ Interpreter’s Signature____________________________
Provider’s Name: _____________________________________ Location: _____________________________________
Interpreter arrival time: _________ am / pm
Type of Request:  Scheduled
 ASAP
End of session: _________ am / pm
 Phone
 Doctors Office  On call
Subject: _____________________
 Other_________________________
Interpreter’s Name: ___________________________________ Interpreter’s Signature____________________________
Provider’s Name: ____________________________________ Location: ______________________________________
Interpreter arrival time: _______ am / pm
Type of Request:  Scheduled
 ASAP
End of session: ________ am / pm
 Phone
 Doctors Office  On call
Subject: _______________________
 Other_________________________
Interpreter’s Name: ____________________________________ Interpreter’s Signature___________________________
FOLLOW UP APPOINTMENTS:
DATE/TIME
PROVIDER
DEPARTMENT
TELEPHONE
COMMENTS:
==============================================================================================
 Interpreter Services are provided to you at no cost. If you do not want a hospital interpreter please sign your name below. Your
signature indicates that you have given us permission to release the hospital appointed interpreter from responsibility in interpreting
for your care on this date.
 El servicio de Intérpretes se ofrece gratis a los pacientes. Si usted no quiere un intérprete del hospital por favor firme abajo. Su
firma indica que está de acuerdo en no usar el intérprete designado por el hospital para su cuidado médico en esta fecha.
 O servico de intérpretes é oferecido gratuitamente ao paciente. Se voce não quer um intérprete do hospital por favor assine abaixo.
A sua assinatura indica que nos da consentimento para não usar o intérprete designado pelo hospital para seu tratamento nesta data.
Person designated by patient to interpret: ___________________________________Relationship: _____________________
Patient Signature: __________________________________________
Date: ___________________________
REQUEST FOR INTERPRETER SERVICES FORM
• Interpretations are counted by encounters, not by patient
• Form is used for inpatients, outpatients, ED, DVNA and Medical
offices
• The white copy goes in the patient chart under “consultations” and
the yellow copy goes to the interpreter services office for statistical
purposes. Per-diem and independent contractors attach the yellow
copies to their invoice for payment.
• One form is used per day.
• In the case of an inpatient or ED patient, the first interpreter to
provide service to that patient leaves the form in the patient’s chart
to be used by the next interpreter during that same day. The medical
records office returns the yellow copy to the ISO, if for some reason
it is left in the patient’s chart.
• The interpreter administers the waiver and the provider also
documents the refusal of interpreter.
Interpreter Service
Department
METROWEST MEDICAL CENTER
Raquel Santander-Nelson
Coordinator, Development, Education
508-383-8289
[email protected]
Name:
0
Interpreter Daily Log
Face-toFace Visit
or
Telephonic
Date
Category Department Encounter
3/2/2007 Clinics
Clinic, ID Visit
3/2/2007 Inpatient 5th Floor Visit
3/2/2007 Inpatient Cardiology Visit
3/5/2007 Clinics
Clinic, MedicalVisit
3/5/2007 Clinics
Clinic, MedicalVisit
3/5/2007 Clinics
Clinic, MedicalVisit
3/5/2007 Clinics
Clinic, MedicalVisit
Time of Time of
Patient Last Patient
Name First Name
Request Call Back Start Time End Time Language Comments
Morais
Francisca
10:00 AM 10:10 AM Portuguese
Delfino
Maria
10:30 AM 10:45 AM Portuguese
Mara
11:00 AM 11:15 AM Portuguese
Silva
Carmen
10:40 AM 10:50 AM Portuguese
Rodriguez Mildred
11:00 AM 11:05 AM Spanish
Silva
Carmen
11:10 AM 11:25 AM Portuguese
Rodriguez Maria
11:30 AM 11:40 AM Spanish
Interpreter Service by the numbers
• Total # of encounters for 2006 = 19,877
• Total # of Emergency Dept sessions for 2006 =
11,081 (55.7% of all encounters are designated as Emergency
Dept)
• Total # of Spanish interpreting sessions =7,399
• Total # of Portuguese interpreter sessions =
12,478
• Total # of On-Call = 4,013
Volume by Department (top ten)
Emergency Dept
11081
Clinic, Pedi
4144
Clinic, Medical
984
Clinic, Ob/Gyn
733
Maternity
706
Pediatrics, 1st Floor
237
01/01/2006-12/31/2006
0
2000
4000
6000
8000
10000
12000
Percent By Category
Outpatient
21.0%
Other-not
clinical
0.3%
Clinics
20.1%
On-Call***
20.7%
Inpatient
4.5%
01/01/2006-12/31/2006
Emergency
&Access
33.5%
Mount Auburn Hospital
330 Mount Auburn Street
Parsons 3
Cambridge, MA 02138
Contact Susan Prieto
Coordinator of Interpreter Services
617-499-5750
[email protected]
Due to problems with screen
shots, we are not able to include
Sue’s original slides. However,
the information she shared in
the session follows.
Mount Auburn uses Meditech software for EMR.
Staff interpreters document in the electronic medical
record.
Contract interpreters have limited access to document in
the EMR.
Reports can be generated from the various fields in
Meditech. Fields can be added to track area-specific
information.
System is web based. So, theoretically an interpreter or
contract interpreter can document from any terminal in the
hospital.
TIM MORIARTY
SUPERVISOR
INTERPRETER SERVICES
BAYSTATE MEDICAL CENTER
SPRINGFIELD, MA 01199
(413) 794-2502
[email protected]
Baystate Health
Current State:
•Documenting Outpatient Encounters in Stand Alone Software in Visual
Basic. Slide 18 (Did not have access to EMR for 2 years.)
•Inpatient Encounters Now Documented in Cerner Millenium Power Chart
Electronic Medical Record. Slide 19
•All In-Patients Whose Primary Language Is Not English Populate MultiPatient Task List Indicating Name, Language, Location. Name
Drops Off When Patient Discharged. Double Click Name on List
to Complete Patient Encounter Form. Slide 20
•EMR Power Form Based on Stand Alone Software, but Improved.
•Interpreter Encounters Listed Alongside Nursing Assessments, Social
Work Encounters, etc. Slide 21
•Reports Generated Monthly Including Total Encounters Per Unit, Total
Patients Per Unit, Total Encounters Per Interpreter, Total
Encounters Per Language
•Within Next Six Months, Move Outpatient Encounters to EMR.
For questions regarding this
presentation, please contact the
Interpreter Services coordinator
for that part of the presentation,
or contact:
Tim Moriarty
Secretary of FOCIS
[email protected]