1. Hospital
Name
Hospital/Department
Address
Hospital/Department
City
Hospital/Department
Zip Code
Department
Manager's Name & Credentials
Department
Managers Title
2.
2a. Total
Number of Discharges in each Cateogry:
Inpatient
Same
Day Surgery
ER
Ancillary
Outpatient
OR
2b. Volume
of Backlog CHIS, Inc. will be responsible to Code
2c. %
of Discharges in each Category:
Medicare
OB
Cardiac
Surgery
Same
Day Surgery
ER
Records
3.
3a.
Will
CHIS, Inc., staff code only Day Groups by Discharge Day
Will
your hospital give us specific charts your staff has chosen
for us to code?
4.
4a. Name
of Abstracting System
4b. List
abstracting items that you will require CHIS, Inc. staff
to abstract OTHER than the UHDDS required items. (Please
include all QA items that need to be abstracted also)
4c. #
of screens from the time the account number or medical record
number is entered to complete the abstract.
4d. Average
# of seconds for your systems to change to the next abstracting
screen.
5. Name
of Encoder?
6.
6a. Will
charts needing to be coded ALWAYS be assembled?
6b. Will
charts always be in the same area to be picked up?
7.
7a. Other
than the standard operative procedures, what no surgical
procedures do you code, i.e.: CAT scn, MRI, radiology, ultra
sound, etc.
7b. Do
you have a limit for the number of diagnosis and procedures
coded? If so how many in each category?
8.
8a. Number
of open desks and terminals available to CHIS, Inc. coders?
Please list the days and time of days if needed.
9.
9a. List
other duties Coders will be required to complete, i.e. handwriting
codes on face sheets, writing out dx, flagging charts for
incomplete, writing their initials and date the chart coded,
crossing chart off discharge logs, etc.
10.
10a. Do
you have a Physician Query Process?
10b. If
yes then please list.
11.
11a. Do
you use special indicators in your Abstracting Systems?
(i.e. NI, URO, etc.)
11b. If
yes, then please list.
Signature:
Please type your name in place of a signature and date where
appropriate. Date:
