Health Information Management Technology PDF

Health Information Management Technology: An Applied Approach, Sixth Edition Chapter 4: Health Record Content and Documentation ahima.org ahima.org © 2020 AHIMA Documentation Recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of commun...

Health Information Management Technology: An Applied Approach, Sixth Edition Chapter 4: Health Record Content and Documentation ahima.org ahima.org © 2020 AHIMA Documentation Recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregivers Allows for the telling and retelling of events ahima.org © 2020 AHIMA Impact of Poor Documentation Poor outcomes Issues with patient care Issues with the accuracy of diagnosis and procedure codes Errors on healthcare claim ahima.org © 2020 AHIMA Documentation Standards Describes those principles, codes, beliefs, guidelines, and regulations that guide healthcare documentation. Dictates how healthcare providers should document the treatment and services within the health record. ahima.org © 2020 AHIMA Standard Set of principles, codes, beliefs, guidelines, and regulations that have been vetted and agreed upon by an individual or a group of individuals. ahima.org © 2020 AHIMA Documentation Standard Standard that controls health record documentation ahima.org © 2020 AHIMA Documentation Standards and EHRs EHRs and paper-based health records typically have the same basic documentation standards Templates ahima.org © 2020 AHIMA Standards Documentation standards have grown in complexity and detail over time Focus on Patient care quality Appropriate reimbursement Prevention of fraud and abuse ahima.org © 2020 AHIMA Standards Documentation standards vary upon the type of health record Multiple sources of documentation standards: Insurance company or payers Government regulatory agencies Licensing boards Accrediting bodies Facility policies and procedures Medical staff bylaws ahima.org © 2020 AHIMA Goals of Documentation Standards Ensure complete health record and accurately reflects the treatment provided to the patient Drive appropriate reimbursement through accurate code capture ahima.org © 2020 AHIMA Medical Staff Bylaws Standards governing the practice of medical staff members Voted on by the organized medical staff and the medical staff executive committee Approved by the healthcare organization’s board of directors Used to enforce quality of care ahima.org © 2020 AHIMA Medical Staff Bylaws Required by Licensure organizations Accreditation organization Federal and state regulatory agencies Each organization mandates content Medical staff bylaws will vary slightly from one organization to another ahima.org © 2020 AHIMA Medical Staff Physicians and nonphysician providers who have privileges to practice medicine at a particular healthcare organization May or may not be employed by the healthcare organization Medical staff are subject to the medical staff bylaws ahima.org © 2020 AHIMA Medical Staff Privileges Specific services and procedures that the medical staff member is deemed qualified to perform, at a particular healthcare provider organization ahima.org © 2020 AHIMA Accreditation A voluntary process Periodical evaluation against preestablished written criteria Healthcare organizations measure their own compliance with standards Enhances the reputation of the organization in the eyes of the patient Differs by the type of program or service ahima.org © 2020 AHIMA Accreditation Healthcare organizations that are accredited by an approved accreditation organization are exempt from routine state survey agencies ahima.org © 2020 AHIMA Accreditation Organization Must go through its own CMS review to obtain deemed status Evaluates healthcare organizations for compliance with CoPs and CFCs ahima.org © 2020 AHIMA Joint Commission Accredits wide variety of healthcare organizations Continuously updates survey processes Surveys clinical and operational components Provides education to healthcare organizations related to compliance ahima.org © 2020 AHIMA Joint Commission Provides accreditation for: Ambulatory healthcare Behavioral health Critical access hospital Homecare Hospital Laboratory Nursing care centers Physician offices Office-based surgery centers ahima.org © 2020 AHIMA Other Accreditation Organizations Healthcare Facilities Accreditation Program Commission on Accreditation of Rehabilitation Facilities Accreditation Association for Ambulatory Healthcare ahima.org © 2020 AHIMA State Statutes Legislation written and approved by a state legislature and then signed into law by the state’s governor Addresses the documentation requirements for specific types of health records ahima.org © 2020 AHIMA Legal Health Record Documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information Content varies from provider organization to another ahima.org © 2020 AHIMA Legal Health Record Policies and procedures should be established to defining legal health record ahima.org © 2020 AHIMA General Documentation Guidelines Apply to all categories of health records Every healthcare organization should have policies Organized systematically to facilitate data retrieval and compilation ahima.org © 2020 AHIMA General Documentation Guidelines Only individuals authorized by the organization’s policies should be allowed to enter documentation in the health record. Organizational policy or medical staff rules and regulations should specify who may receive and transcribe verbal physician’s orders. ahima.org © 2020 AHIMA General Documentation Guidelines Health record entries should be documented at the time the services they describe are rendered. Authors of entries should be clearly identified in the record. Only abbreviations and symbols approved by the organization or medical staff rules and regulations should be used in the health record. ahima.org © 2020 AHIMA General Documentation Guidelines All entries in the health record should be permanent. Any corrections or information added to the record by the patient should be inserted as an addendum No changes should be made in the original entries in the record Information added to the health record by the patient should be clearly identified as an addendum ahima.org © 2020 AHIMA CMS Documentation Requirements Entries must be Legible Complete Dated and timed Author identified Authenticated in written or electronic form ahima.org © 2020 AHIMA Authentication Identifying the source of health record entries Written signature Initials Electronic signature CMS requires controls to prevent any changes from being made to the health record after the entries have been authenticated ahima.org © 2020 AHIMA Auto-Authentication When a physician or other care provider authenticates an entry without reviewing ahima.org © 2020 AHIMA Documentation by Setting Health record information consists of two types regardless of setting Clinical Administrative ahima.org © 2020 AHIMA Documentation by Setting Must have health record for each person Content varies by setting Contains clinical and administrative data ahima.org © 2020 AHIMA Inpatient Health Record Patient stays overnight Medical or surgical Most complex health record ahima.org © 2020 AHIMA Inpatient Health Record—Clinical Medical history Current condition Past medical history Personal history Family history Chief complaint ahima.org © 2020 AHIMA Inpatient Health Record—Clinical Physical exam Physician assessment Diagnostic and therapeutic procedure order Physician order Standing order ahima.org © 2020 AHIMA Inpatient Health Record—Clinical Clinical observation Progress note Integrated health record Summary statement (death) Care plan ahima.org © 2020 AHIMA Inpatient Health Record—Clinical Autopsy report Vital signs Flow charts Diagnostic and therapeutic procedure reports Lab, pathology, and radiology and other tests/treatments ahima.org © 2020 AHIMA Inpatient Health Record—Clinical Anesthesia report Operative report Recover room report Pathology report Consultation report ahima.org © 2020 AHIMA Inpatient Health Record—Clinical Discharge summary Overview of encounter Not required for hospitalization less than 48 hours, uncomplicated delivery or newborn Patient instructions Transfer records ahima.org © 2020 AHIMA Inpatient Health Record—Administrative Patient registration Demographics ahima.org © 2020 AHIMA Special Health Records Some health records have unique requirements because of the specialized services provided ahima.org © 2020 AHIMA Obstetric and Newborn Health Record Obstetric Prenatal Labor and delivery Newborn APGAR ahima.org © 2020 AHIMA Ambulatory Health Record - General Demographics Problem list ahima.org © 2020 AHIMA Ambulatory Surgery Record Similar to inpatient surgical health record Follow-up post surgery ahima.org © 2020 AHIMA Ancillary Departments Tests and procedures ahima.org © 2020 AHIMA Physician Office Record Preventive care Minor illnesses and injuries ahima.org © 2020 AHIMA Long-Term Care Ongoing assessments Care plan Resident Assessment instrument Minimum Data Set for Long-Term Care ahima.org © 2020 AHIMA Rehabilitation Minimum Data Set, Version 3 (MDS 3.0) Resident Assessment Instrument 5-Day Assessment (mandatory) Interim Payment Assessment (optional) Discharge Assessment (mandatory) ahima.org © 2020 AHIMA Behavioral Health Includes similar content Family and caregiver input is documented ahima.org © 2020 AHIMA Home Health Treatment plan Health assessment Problem list Treatment goals Interventions and outcomes ahima.org © 2020 AHIMA Federal and State Initiatives on Documentation Trends are to focus on Quality of care provided Value-based care Reimbursement provide incentives for quality of care MACRA Core Measures ahima.org © 2020 AHIMA Paper Health Record—Format Source-oriented health record Universal chart order Integrated health record Problem-orientated medical record Subjective, Objective, Assessment, Plan (SOAP) ahima.org © 2020 AHIMA Electronic Health Record Point-of-care documentation Documentation captured electronically ahima.org © 2020 AHIMA Web-Based Document Imaging Capture, digitize, integrate, store, and retrieve paper-based health record documentation Organizes and assembles the paper-based health record documentation, and controls the versioning, access, and search capabilities of the documentation ahima.org © 2020 AHIMA Role of Healthcare Professionals in Documentation Physicians Document appropriately so that quality care can be rendered and that appropriate reimbursement can occur ahima.org © 2020 AHIMA Role of Healthcare Professionals in Documentation Nurses Documentation varies by licensing and regulatory requirements, setting, and internal policy and procedures ahima.org © 2020 AHIMA Role of Healthcare Professionals in Documentation Allied Health Professionals Many follow treatment plan developed by the patient’s physician or a therapist or technologist Documents treatment and patient’s response ahima.org © 2020 AHIMA HIM and Documentation Plays vital and different roles in the overall governance of health record information Manages many aspects of the health record and its content Used in coding, billing, and other HIM functions ahima.org © 2020 AHIMA HIM Roles Clinical documentation integrity coordinator Analyst ahima.org © 2020 AHIMA