Medical Record Procedure Reminders
• When forwarding progress notes, lab reports, and other medical record documentation to Health Information Services (formerly Medical Records) to be filed, be sure each document has the patient name and BWH medical record number.
• The location of all medical records are tracked in BICS, and any records removed from their designated location (pod, clinic, or department) must be re-tracked in BICS. Please call ext. 6060 if you are taking a medical record from one location to another. Do not hold medical records following discharge.
• Sign all medical record documents, operative notes, discharge summaries, history and physicals, consults, and clinic notes in a timely fashion. Transcribed documents not reviewed/signed within 14 days will note, “not reviewed by physician/author.” You may sign the documents after 14 days by going into CI/D/C/provider/date, but may not edit after 14 days. Any changes after 14 days require an addendum. Once signed, the record will indicate “reviewed by physician/author.”
• Please require overdue discharge summaries to be dictated by the Residents. Any discharge summaries undictated by Residents who have left BWH will be reassigned to the Attending physician.
• The automated discharge summary was launched on June 26, 2000 for discharges with a length of stay of six days or less (six midnights). To complete a comprehensive discharge summary using the discharge order template at the time of discharge, see the following guidelines:
- No abbreviations
- List all Diagnoses treated
- List all procedures and any procedures not done in the OR
- List history of present illness and hospital course in brief resume
- Do not type in “uncomplicated” or “uneventful” in the brief resume section
• BICS E-mail Disclaimer. The BWH Medical Record Committee and Confidentiality Task Force has approved a BICS e-mail disclaimer to be added to all BICS e-mail, similar to the disclaimer on BWH fax cover sheets. The email disclaimer will read:
This message is privileged and confidential. Any review, retransmission, dissemination, or other use of this information by other than the intended recipient is prohibited.
Clinical E-Mail Guidelines
The Internet does not provide secure media for transporting confidential information. If you and your patient agree to use electronic mail, inform patients about privacy issues.
Patients should know that:
• Others besides the addressee may process messages during addressee’s usual business hours, during addressee’s vacation or illness, etc.
• E-mail can occasionally go to the wrong party
• E-mail communication will not necessarily be a part of the
patient’s medical record
• E-mail can be accessed from various locations
• Information may be sent via e-mail to other care providers
Clinical E-Mail Q and A:
Q: Is BICS secure (messaging within BICS)?
A: Yes
Q: Is accessing BICS from a remote workstation secure?
What are the different ways to access BICS remotely and are there differences in security?
A: There are two forms of access for BICS remotely. One
uses PCAnywhere in conjunction with the Partners Remote
Access client (direct dial) with a SecureID token card. It is considered to be secure. The other form of access is the legacy PC Anywhere hosts running BICS at the Brigham. Users dial
in directly to a pool of PC’s with modems directly attached.
It is considered secure, but not as secure as the SecureID token card solution.
Q: If I autoforward BICS email to Outlook, is it secure?
A: Yes, because it does not travel over the public Internet.
Q: Can you autoforward BICS email to email products other than Outlook, if so is it secure?
A: Yes, however, it is not considered to be secure because
the potential is there to forward that traffic over the public Internet, thereby making it unsecure.
Q: If you send BICS email to an Internet address is it secure?
A: No, if the email is sent to the public Internet it is not encrypted, thereby making it unsecure.
Q: Is sending PHS Outlook mail to another PHS Outlook user secure?
A: Yes
Q: Is accessing Outlook from a remote workstation secure? What are the different ways to access Outlook remotely and are there differences in security?
A: There are currently two ways of securely accessing Outlook from a remote workstation. If accessing via the Partners Remote Access client (direct dial) with a SecureID token card, it is considered to be secure. If accessing via the Outlook Web Access using a web browser and the email
URL (https://phsexchweb.partners.org/exchange)
it is considered to be secure, as it uses encryption by default.
For more information on medical records procedures, contact Jackie Raymond at ext. 6068.