principal repository (storage place) for data and information about the healthcare services provided to an individual patient. Documents who, what, when, where, why and how of patient care. Primary function to document and support patient care services.
health records aka's per field
acute care patients/patient records - physicians & their offices/medical records - long-term facilities/resident records - ambulatory behavioral health/client records - paper based health records/charts
basic facts about people, processes, measurements, conditions, etc. Can be collected in form of dates, numerical measurements and statistics, textual descriptions, checklists, images, and symbols.
data converted into a form that can be used for a specific purpose; a useful form that has meaning.
electronic health record (EHR) systems
creates and maintains the electronic collection, storage and analysis of healthcare information - interactive.
personal health record (PHR)
a health record initiated and maintained by an individual. owned by the individual and is comprised of data and info from the healthcare providers and the individual. may be paper based or computerized.
electronic health record (EHR)
electronic systems designed for use by healthcare providers and support the legal mandate providers have to document care.
primary purposes of the health record
#1 purpose is patient care delivery then the rest are: patient care management, patient care support processes, financial and other administrative processes, and patient self-management.
patient care delivery
PRIMARY PURPOSE OF THE HEALTH RECORD. the health record documents services provided by clinical professionals and allied health professionals. helps physicians, nurses and other clinical care professionals make informed decisions about diagnoses and treatments. a tool for communication among patient's different caregivers. allows providers to asses and manage risk. represents legal evidence of the services received by patient and represents the business of the organization.
patient care management
all the activities related to managing the healthcare services provided to patients. assists providers in analyzing various illnesses, formulating practice guidelines and evaluating quality of care.
patient care support processes
encompasses activities related to handling of healthcare organizations resources, analysis of trends and communication of info among different clinical depts.
financial and other admin processes
info in health record determines the payment provider will receive in every type of reimbursement system. the data elements are trended to assist in managing and reporting costs.
patient self management
individuals have become more actively involved in managing their own health and healthcare and therefore are becoming a primary user of the health record.
secondary purposes of the health record
not associated with specific encounters between patient and healthcare professional but related to environment in which patient care is provided. education, research, regulation, policy making, public health, homeland security, industry.
other users of health records
individuals and organizations, managed care organizations, integrated healthcare delivery systems, regulatory and accreditation organizations, licensing bodies, educational organizations, third-party payers, research facilities.
users of health records defined
those individuals who enter, verify, correct, analyze, or obtain info from the record, either directly or indirectly through an intermediary.
individual users of the health record
providers, consumers (families/patients), patient care mgmt and support (adminstrators, financial mgrs, quality mgrs, record professionals, risk mgrs), patient care reimbursement (benefit mgrs and insurers), other (accreditors, govt policy makers, legislators, lawyers, researchers, journalists), employers, law enforcement
collected data from various sources used to identify patterns/trends, based on this managers recommend changes to patient care processes, equipment and services.
institutional users of the health record
healthcare delivery organizations (hospitals/nursing homes/ambulatory surgery centers), third-party payers, medical review organizations, research organizations, educational organizations, accreditation organizations, government licensing agencies, policy making bodies, employers
primary function of health record
to store patient care documentation (attributes associated with the storage function are quality, accessibility, security, flexibility, connectivity and efficiency)
data quality mgmt model
based on 4 domains: data applications (purposes for which data are collected), data collection (processes by which data are collected), data warehousing (processes & systems, by which data are archived), data analysis (processes by which data are translated into info that can be used for designated application)
accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, timeliness
data are correct. data should represent what was intended or defined by the original source of the data. depends on patient's physical and emotional state at time data collected, provider's interviewing skills, provider's recording skills, availability of the patient's clinical history, dependability of the automated equipment, and reliability of the electronic communications media.
the data are easily obtainable. any organization with health records for individual patients must have systems in place that identify each patient and support efficient access to info on each patient. users must be able to access info easily when and where they need it. every system should allow record access 24 hrs a day regardless of format stored in. Factors affecting accessibility: whether previous records are available when/where needed, whether dictation equipment is accessible and working properly, whether transcription is accurate, timely and readily available to providers, and whether computer data entry devices are working properly and are readily available to providers.
all the required data elements are included in the health record. means that the record is complete. must include patient identification, consents for treatment, advance directives, problem list, diagnoses, clinical history, diagnostic test results, treatments and outcomes, and conclusions and follow-up requirements.
that data are reliable. reliable data do not change no matter how many times or in how many ways they are stored, processed or displayed. data values are consistent when value of any given data element is the same across applications and systems.
data currency/data timeliness
that healthcare data should be up-to-date and recorded at or near the time of the vent or observation.
that the data and information documented in the health record are defined. for information to be meaningful, it must be pertinent. users of the data must understand what the data mean and represent. every data element should have a clear definition and range of acceptable values.
that the attributes and values of data be defined at the correct level of detail for the intended use of the data.
term used to describe expected data values. the acceptable values or value ranges for each data element must be defined. precise data yields accurate data collection.
that the data in the health record are useful. the reason for collecting the data element must be clear to ensure the relevancy of the data collected.
the expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose.
the protection of the privacy of individuals and the confidentiality of the health records. allows only authorized users to access health records. also includes the protection of healthcare info from damage, loss and unauthorized alteration.
American Health Information Management Association (AHIMA)
underlying purpose to ensure the quality, confidentiality and availability of health information across diverse organizations, settings and disciplines.
Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM)
current accreditation agency for degree-granting programs sponsored by AHIMA started in 2004. serves the public interest by establishing quality standards for educational preparation of future HIM professionals.
Commission on Certification for Health Informatics and Information Management (CCHIIM)
develops and administers qualify examination for HIM registration. established in 2008. dedicated to assuring the competency of professionals practicing in HIM. serves the public by establishing, implementing and enforcing standards and procedures for certification and recertification of HIM professionals. provides strategic oversight of all AHIMA programs.
Association of Record Librarians of North America (ARLNA)
formed in 1928, 10 yrs after hospital standardization movement, objective to elevate the standards of clinical recordkeeping in hospitals, dispensaries and other healthcare facilities, 58 members first year, predecessor to AHIMA
American Health Information Mgmt Association (AHIMA)
underlying purpose to ensure the quality, confidentiality and availability of health information across diverse organizations, settings and disciplines.
Automated systems worked with
master patient index (MPI), healthcare information system (HIS), clinical information system (CIS), electronic health record system (EHR), electronic document management system (EDMS), HIM dept information system (HIMIS), revenue cycle management system (RCM), voice/text/speech system (VTS), registry information system (RIS)
Steps influenced development of HIM
the hospital standardization movement, the organization of records librarians, and the approval of formal educational processes and a curriculum for medical record librarians.
medical record history
physician responsibility, practically worthless, consisted principally of nurse's notes, often filed as received on discharge of patient, no standard vocabulary to document why patient admitted or diagnosis
Hospital standardization Program
purpose to raise the standards of surgery by establishing minimum quality standards for hospitals, state most important item to patient was a complete/accurate report of care and treatment during hospitalization
communities of practice (CoP)
a virtual network of AHIMA members who communicate via a web-based program managed by AHIMA. Only open to AHIMA members and provides following benefits: opportunities to contact other members for quick problem solving, support, advice, and career-building tips and opportunities (and to share best practices), makes it possible for members to search for other members with similar interests and backgrounds, provides links to other sites that have specialized HIM info, includes a professional library of HIM standards/guidelines/practice briefs/resources
House of delegates
extremely important component of the volunteer structure. conducts official business of organization and functions as AHIMA's legislative body. Each state HIM association elects representatives to the House of Delegates to serve for a specified term of office. similar to the legislative branch of the US govt.
component state associations (CSAs)
AHIMA supports a system of component organizations in every state plus Washington DC and Puerto Rico. provide members with local access to professional education, networking and representation. an important forum for communicating info relevant to nat'l issues and keeping members informed of regional affairs that affect HIM. many states also have local and regional organizations.
AHIMA staff structure
headquarters in Chicago. staff required to run day to day ops of organization is organized into # of divisions. Exec director responsible for overseeing day to day ops. A team of execs, managers, and staff support the exec director. Some depts include member services, education, professional practice services, publications, marketing, and policy and govt relations.
for the health record to fulfill its intended purposes, health record data should be flexible enough to meet the needs of all the records different users. paper-based cannot realize this flexibility w/standardized forms. when designed appropriately, EHR systems can be extremely flexible in the way they display and present info. authorized caregivers and other legitimate health record users display the info they need in the format they prefer.
source oriented health record format
organizes the information according to the patient care dept that provided the care. grouped together according to their point of origin. those filing reports can do so easily simply by looking at source/date. end users of info filed in record do not have easy time as they must search by date of occurrence in each of the groups of info.
problem oriented health record format
a documentation approach in which the physician defines each clinical problem individually. info about the problems is organized into 4 components: the database, the problem list, initial plans and progress notes. better suited to serve the patient and end user of patient info. each problem indexed with a unique number.
integrated health record format
organizes all paper forms in strict chronological order and mixes the forms created by different departments. advantage is that it is easy to follow the course of the patient's diagnosis and treatment. disadvantage is format makes difficult to compare similar types of info.
document that patient's medical condition, diagnosis and procedures performed as well as the healthcare treatment provided. going to have the most of this type of data. patient's medical history, report of patient's initial physical exam, attending physician's diagnostic and therapeutic orders, clinical observations of the providers who care for the patient, reports and results of every diagnostic and therapeutic procedure performed, reports of consulting physicians, patient's discharge summary, final instructions to the patient upon discharge.
demographic and financial information as well as various consents and authorizations related to the provision of care and the handling of confidential patient information.
statements of expected behavior or reference points against which structures, process or outcomes can be measured.
standards for documentation
facility specific standards, licensure requirements, government reimbursement programs, accreditation standards
#1 standard for documentation. might be found in facility policies and procedures and, when a facility has an organized medical staff, in the medical staff bylaws, rules and regulations. govern the practice of physicians and others within a specific organization.
#2 standard for documentation. before they can provide services, most healthcare organizations must be licensed by government entities such as the state or county in which they are located and must maintain a license as long as care is provided., compliance with state licensing laws is required in order to begin or remain in operation within their states. varies from state to state.
government reimbursement programs
standards are applied to facilities that choose to participate in federal govt reimbursement programs such as Medicare and Medicaid, and called Conditions of Participation. Facilities are said to be certified if the standards are met. participating organizations receive funds and must follow the conditions of participation.
accreditation is the end result of an intensive external review process that indicates a facility has voluntarily met the standards of the independent accrediting organization. seek public recognition through accreditation with recognized accrediting bodies. must meet specific documentation standards.
Conditions of Participation
standards that are applied to facilities that choose to participate in federal govt reimbursement programs such as Medicare and Medicaid.
a complete medical history documents the patient's current complains and symptoms and lists his or her past medical, personal and family history.
physical examination report
represents the attending physician's assessment of the patient's current health status. should document info on all the patient's major organ systems. when combined with medical history, it is referred to as H&P, and is usually on one form and on chart at hospital w/in 24 hrs
instructions the physician gives to the other healthcare professionals who actually perform diagnostic tests and treatments, administers medications and provide specific services to a particular patient. all orders must be legible and include the date (and possibly time) and the physician's signature.
orders the medical staff or an individual physician have established as routine care for a specific diagnosis or procedure.
physicians may communicate orders verbally or via the telephone when the hospitals medical staff rules allow.
documentation of clinical observations. purpose of documenting the clinical observations of physicians, nurses and other caregivers is to create a chronological report of the patient's condition and response to treatment during his or her hospital stay. serve to justify further acute care treatment in the facility. they document appropriateness and coordination of the services provided.
the rules and regulations of the hospital's medical staff specify which providers are allowed to enter progress notes in the health record. typically the patient's attending physician, consulting physician, who have medical staff privileges, house medical staff, nurses, nutritionists, social workers and clinical therapists, are authorized to enter progress notes. each discipline may maintain a separate section of the health record or the observations of all the providers may be combined in the same chronological or integrated health record.
summary of the patient's problems from the nurse or other professional's perspective with a detailed plan for interventions.
nursing and allied health notes and assessments
nurses and allied health professionals may begin their care with assessments focused on understanding the patient's condition from the perspective of their specialized body of knowledge.
include lab tests performed on blood/urine/other samples from the patient, pathological exams of tissue samples and tissues or organs removed during surgical procedures, radiological scans and images of various parts of the patient's body and specific organs, monitors and tracings of body functions.
procedure and surgical documentation
any major diagnostic procedure or surgical event requires special documentation. preop notes by anesthesiologist and surgeon. when tissue removed, path report must also be present.
assumed when a patient voluntarily submits to treatment. the rationale behind this assumption is that one can reasonably assume that the patient understands the nature of the treatment or would not submit to it.
consent that is either spoken or written. spoken consent is more difficult to prove.
notes any preoperative medication and response to it, the anesthesia administered with dose and method of administration, the duration of administration, the patient's vital signs while under anesthesia, and any additional products given to the patient during the procedure.
describes surgical procedures performed on each patient. pre- and post-op diagnosis, description of procedures performed, all normal/abnormal findings, estimated blood loss, description of specimens removed or any unique or unusual events during course of surgery, date and duration
recovery room report
includes the postanesthesia note, nurses notes regarding patient's condition and surgical site, vital signs, and intravenous fluids and other medical monitoring.
dictated by pathologist after exam of tissue received for evaluation. usually includes descriptions of tissue from a gross or macroscopic level and representative cells at the microscopic level along with interpretive findings.
documents the clinical opinion of a physician other than the primary or attending physician. consultation is requested by the primary or attending physician. based on the consulting physician's exam of patient and a review or their health record.
concise account of patient's illness, course of treatment, response to treatment, and condition at the time patient is discharged. includes instructions for follow-up care to be given to the patient or caregiver at time of discharge. responsibility of and must be signed by attending physician.
discharge summary purpose
ensures continuity of future care by providing info to patient's attending physician, referring physician or any consulting physicians, provides info to support the activities of the medical staff review committee, provides concise info that can be used to answer info requests from authorized individuals or entities.
it is vital that the patient be given clear, concise instructions upon discharge so that progress in recovery from hospitalization continues. should be signed by doc and patient and copied and made part of health record.
form created when patient is being transferred from acute care setting to another healthcare organization. also called a referral form.
description of the exam of patient's body after he or she has died. conducted when question of cause of death or when info needed for educational or research purposes.
a record on newborn is generated upon live birth. identification usually includes bands worn by mom and baby and the infant's footprints, measurements
separate from infant's record and begins in practitioner's office. include prenatal care summary, record of labor, type of delivery, medications given, evaluation of placenta and cord. data about baby also recorded.
demographic and financial info
patients full name, facility identification or acct #, address, telephone #, date and place of birth, gender, race or ethnic origin, marital status, name and address of patient's next of kin, date and time of admission, hospital's name, address and telephone #
consent to treatment
type of consent that documents patient's permission for routine services, diagnostic procedures and medical care.
requires providers with a direct treatment relationship with a patient to secure the patient's written acknowledgement that he or she received the provider's notice of privacy practices.
authorization to disclose information
allows the healthcare facility to verbally disclose or send health information to other organizations. patient or legal rep signs it. covered providers are required to obtain written authorization for use or disclosure of protected health info for purposes not related to treatment, payment or healthcare operation.
written document that names the patient's choice of legal representative for healthcare purposes. designated person then empowered to make healthcare decisions on behalf of patient in event patient is no longer capable of expression his/her preferences. examples are living wills and durable powers of attorney for healthcare.
Physician orders for "do not resuscitate". should be consistent with patient's advance directives.
physician orders for "do not attempt intubation". should be consistent with patient's advance directives.
Patient Self Determination Act (PSDA)
went into effect in 1991. requires healthcare facilities to provide written info on patient's right to execute advance directives and to accept or refuse medical treatment.
Patient's bill of rights
requires hospitals to tell patients who is providing treatment, confidentiality, receive info about treatment, refuse treatment, participate in care planning, be safe from abusive treatment
emergency care documentation
patient id (or reason not obtained), time and means of arrival at facility, emergency care given to patient prior to arrival, diagnostic impression, medications administered
basic ambulatory documentation
registration forms, problem lists, medication lists, patient history questionnaires, history and physicals, progress notes, results of consultations, diagnostic test results, misc flow sheets, copies of records of previous hospitalizations/treatment by other practitioners, correspondence, consents to disclose info, advance directives
function is to facilitate ongoing patient care management. describes any significant current and past illnesses and conditions as well as the procedures the patient has undergone. may include info on patient's previous surgeries, allergies and drug sensitivities.
ob/gyn care documentation
sexual practices including high risk behaviors and method of contraception, periodic lab tests including pap tests and mammography, cholesterol and fecal blood tests, STD testing, HIV testing
ambulatory surgical care documentation
preop studies, findings and techniques of operation, allergies and drug reactions, record of anesthesia administration, documentation of patient's informed consent to treatment, discharge diagnosis
long term care documentation
provided in skilled nursing facilities, subacute care facilities, nursing facilities, intermediate care facilities, ICFs for mentally retarded/disabled, assisted living faclities, based on ongoing assessments and reassessments, personal property list to include furniture and electronics, RAI/MDS and care plan, rehabilitation therapy notes (physical, occupational and speech)
Resident Assessment Instrument (RAI)
care plan format required by federal regulation. based on minimum data set for long term care. includes MDS, triggers, utilization guidelines, and resident assessment protocols. patient is assessed and reassessed at defined intervals as well as whenever there is a significant change in his or her condition. is a critical component of the health record.
Minimum Data Set (MDS) for long-term care
instrument specified by the Centers for Medicare and Medicaid Services that requires nursing facilities (medicaid and medicare certified) to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity.
resident assessment protocol (RAP)
a summary of long term care resident's medical condition and care requirements.
Outcomes and Assessment Information Set (OASIS)
standardized patient assessment instrument used by medicare certified home healthcares. OASIS items are a component of the comprehensive assessment that is the foundation for the plan of care. is completed at start or resumption of care, with each 60 day episode, with a significant change in condition and upon patient transfer or discharge. submitted electronically to state then to CMS.
home healthcare documentation
initial database/demographics and service agreement, certification and plan of treatment, physician's orders, documentation by each discipline involved in home care including treatment plans, summaries and other progress notes, OASIS-C, plan of care, case conference notes
hospice care documentation
includes palliative care that is provided to terminally ill patients and supportive services to patients and their families. doctor must write an order to enter hospice.
behavioral healthcare documentation
psychiatric history, record of complete patient assessment including complaints of others regarding the patient as well as the patient's comments, written individualized treatment plan, multidisciplinary progress notes related to the goals and objectives outlined in the treatment plan, multidisciplinary case conferences and consultation notes including date of conference or consultation, recommendations made and actions taken
rehabilitation services documentation
designation of a manager for the patient's program, evidence of the patient;'s family or family's participation in decision making, reports of staff conferences, rehab problems/goals/prognosis, reports from orthotic and prosthetic services
patient assessment instrument (PAI)
completed shortly after admission and upon discharge. based on the patient's condition, services, diagnosis, and medical condition, a payment level is determined for the inpatient rehabilitation stay
basic principles of health record documentation
policies to ensure uniformity of content/format, organized systematically in order to facilitate data retrieval and compilation, only individuals authorized allowed to enter into record, specify who may receive/transcribe verbal physician's orders, entries should be documented at time services rendered, authors clearly identified, only abbreviations/symbols approved to be used, errors corrected w/single line and error written w/date, time and initials in paper record, errors corrected via addendum in EHR, HIM dept should develop, implement and evaluate policies and procedures related to quantitative analysis of health records.
format for problem-oriented progress notes. Subjective (S) entry relates significant info in patients words or from patients point of view. objective (O) data includes factual info like lab findings or provider observations. assessment (A) reached by professional conclusions by evaluation of the subjective/objective info. plans (P) and any comments/changes to it complete the framework. if SOAP format is used, only pertinent parts are used.