HealthPartners Graduate Medical Education Resident Handbook 2012-2013 Th is manual contains the policies and procedures for the IME residency programs at Regions Hospital Th e Institute for Medical Education is licensed as a private career school with the Minnesota Offi ce of Higher Education pursuant to Minnesota Statues, sections 141.21 to 141.32. Licensure is not an endorsement of the institution. Credits earned at the institution may not transfer to all other institutions. Graduate Medical Education Resident Handbook 2012-2013 TABLE OF CONTENTS DEPARTMENT DESCRIPTIONS | CLINICAL PAGES Anesthesiology ......................................................................................................................................................................1 Center for International Health .......................................................................................................................................... 2-3 Compliance Operations .........................................................................................................................................................4 Compliance Documentation Management Program..............................................................................................................5 Utilization Management .........................................................................................................................................................6 Emergency Medicine ..........................................................................................................................................................7-8 Food and Nutrition ............................................................................................................................................................9-14 Foot and Ankle Surgery/Podiatry .........................................................................................................................................15 Hand Surgery .................................................................................................................................................................16-17 Health Information Management ....................................................................................................................................18-65 Medical Record Documentation Requirements .................................page 20 Uniform Hospital Discharge Data Set ............................................... page 25 Him Bylaws ....................................................................................... page 26 Dictaphone Dictation Guide .............................................................. page 27 “Do Not Use” Abbreviation, Symbol List ............................................page 33 E-Sig ................................................................................................ page 34 E-Sig Phase 2 ................................................................................... page 36 Edits & Addendas ..............................................................................page 39 Regions Hospital Abbreviation List .................................................... page 41 Symbol Defi nitions ............................................................................ page 63 Appendix A & B ................................................................................. page 64 Chart Completion in Epic 2009 ......................................................... page 65 Infection Control .............................................................................................................................................................66-69 Integrated Home Care .........................................................................................................................................................70 Internal Medicine ............................................................................................................................................................71-73 Medical Toxicology .........................................................................................................................................................74-74 Neurology ............................................................................................................................................................................76 Neurosurgery .......................................................................................................................................................................77 Nursing Services ............................................................................................................................................................78-80 Obstetrics/Gynecology ........................................................................................................................................................81 Occupational Medicine ........................................................................................................................................................82 Offi ce of Integrity and Compliance ......................................................................................................................................83 Ophthalmology ....................................................................................................................................................................84 Orthopedics .........................................................................................................................................................................85 Otolaryngology/Head & Neck Surgery.................................................................................................................................86 Partnering Care/Transitional Care & Long Term Care Services ..........................................................................................87 Patient Relations Department.........................................................................................................................................88-90 Pathology Lab, Anatomic & Clinical .....................................................................................................................................91 Pharmacy Services.........................................................................................................................................................92-96 Plastic & Hand Surgery .......................................................................................................................................................97 Psychiatry ............................................................................................................................................................................98 Radiology......................................................................................................................................................................99-101 Rehabilitation Institute ................................................................................................................................................102-104 Respiratory Care Services/Sleep Health Center ........................................................................................................105-107 Surgery ..............................................................................................................................................................................108 DEPARTMENT DESCRIPTIONS | SERVICES PAGES Care Management Department .........................................................................................................................................109 Chaplaincy Services .......................................................................................................................................................... 110 HealthPartners Research Foundation ........................................................................................................................ 111-112 Linen Services ............................................................................................................................................................ 113-114 Parking .............................................................................................................................................................................. 115 Regions Hospital Medical Library ............................................................................................................................... 116-117 Security.............................................................................................................................................................................. 118 Switchboard Operators/Guest Services ............................................................................................................................ 119 Volunteer Services.............................................................................................................................................................120 2012-2013 i Table of Contents IME/GME POLICIES PAGES IME-32 Access to Eligibility to Board Certifi cation ..................................................................................................121-122 IME-21 Appropriate Dress/Attire ................................................................................................................................... 123 IME-30 DIO Designee