Documentation for Health Records

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Chapter 8 Federal and State Requirements and Accreditation Guidelines

Mandatory rules established by

Federal statutes and regulations; apply across US
State statutes and regulations; apply to individual states
County and municipal ordinances and codes; apply to local communities
State and federal judicial decisions; apply to geopolitical areas

Statute

Legislation written and approved by state or federal legislature, signed by governor or president

Regulation

- Rule established by administrative agency of government

Centers for Medicare and Medicaid Services (CMS) -

example of administrative agency charged with developing and implementing Medicare Conditions of Participation for Hospitals

Acute-care hospitals requirements:

State licensure requirements
State health record regulations
State public health regulations
State rules on Medicaid qualifications
County and municipal building safety codes
HIPAA Privacy and Security rules
Legal doctrines of medical liability

Sources of voluntary rules for acute-care hospitals:

Accreditation organizations (examples: Joint Commission and American Osteopathic Association)
Professional certification organizations (example: board certification)
Standard development organizations (examples: American Society Testing and Materials and Health Level Seven)

Federal and State Requirements

Sources
Federal statutes and regulations
State statutes and regulations
County and municipal ordinances and codes

Statute

A piece of legislation written and approved by a state or federal legislature and then signed into law by the state's governor or the President
HIPAA is an example

Regulation

A rule established by an administrative agency of government
Have the same effect as legislation
Failure to abide by regulations or statutes results in fines and/or disciplinary action

Federal Healthcare Statutes

HIPAA
Protected health information (HI)
Disclose in only two situations:
To individuals when they request access to PHI (with authorization by the patient)
To HHS when it is undertaking a compliance investigation or a review of enforcement action

Permitted Uses and Disclosures

To the patient
Treatment, payment, healthcare operations
Uses and disclosures with opportunity to agree or object
Incidental use and disclosure
Public interest and benefit activities
Limited data set

HITECH Act

Gives HHS the authority to promulgate regulations and guidance to support the development of an interoperable, private, and secure nationwide health information technology infrastructure
ONCHIT - responsible for administering the HITECH Act

HITECH Act Addresses

Standards and Certification
Meaningful Use
Privacy and Security
Electronic Eligibility and Enrollment
Electronic Prescriptions for Controlled Substances

CMS Regulations

Established in 1965 by an amendment to the Social Security Act of 1935
Medicare and federal portion of Medicaid administered by CMS
Local Medicaid programs administered by agencies within individual state governments

Medicaid Participation

Provided through state-run medical assistance programs
Voluntary for healthcare professionals and organizations
Hospitals choosing to participate must apply to state agency administering Medicaid program in local area
Annual surveys conducted by most states to confirm hospital compliance with Medicaid regulations

Medicare Conditions of Participation

Medicare is the largest single payer for healthcare services
Participation is voluntary
Few hospitals would survive economically if they did not provide services to Medicare beneficiaries
Published under title 42, part 482 of the Code of Federal Regulations in the Federal Register

Medicare Conditions of Participation Standards

Standards similar to acute care standards published by the Joint Commission and AOA
Lists requirements of medical record services in a hospital
Addresses organization and staffing of the HIM department
Addresses health record format and retention requirements
Describes content requirements for documentation
Requires hospitals to protect patients' personal and medical rights

Medicare Conditions of Participation Standards - cont'd

Other sections that include documentation requirements:
Medical staff
Nursing services
Radiology services
Laboratory services
Discharge planning
Surgical services
Anesthesia services
Nuclear medicine services

Patient Satisfaction as a Quality Measure

Added as a measure of quality
Hospital patient perspectives data are published to help consumers make more informed hospital choices
Creates incentives for hospitals to improve quality of care

Office of Inspector General (OIG)
Work Plan for Hospitals 2011: HIM-related Activities

Reliability of hospital-reports quality measure data
Hospital readmissions
Hospital admissions with conditions coded "present on admission"
Early implementation of Medicare's policy for hospital-acquired conditions
Hospital inpatient outlier payments

Recovery Audit Contractors

RACs
Purpose is to reduce improper Medicare payments and prevent future improper payments made on claims of healthcare services provided to Medicare beneficiaries
Prevents overpayments and underpayments
In March 2008, ended with more than $1.03 billion recovered

Federal Requirements for Special Health Record Protection

Records of psychiatric care and psychotherapy
Records of substance abuse treatment
Records of HIV/AIDS diagnosis and treatment
Records that contain genetic information

HIV Testing

Many states have HIV/AIDS reporting requirements and antidiscrimination laws
HIV testing is basically voluntary in US
May be mandatory for specific groups of employees
Some states prohibit mandatory employee testing
Court orders differ from state to state
Consult legal counsel before establishing policies and procedures related to HR issues

Confidentiality Issues Related to HIV/AIDS

Most state regulations address confidentiality in three areas:
Consent for testing
General information on testing
Reporting of test results
Individuals must sign a formal informed consent before testing

Records Containing Genetic Information

Usually no special protection under state health record regulations
Difficult to protect information from inadvertent disclosure
HIPAA addresses health insurance discrimination based on genetic information
Several states enacted similar health insurance and genetic testing regulations

Joint Commission Evaluation and Accreditation Services

Acute-care hospitals
Ambulatory-care organizations
Behavioral healthcare facilities
Children's hospitals
Critical-access hospitals
Group practices
Home-care organization
Hospice services
Independent or freestanding laboratories
Long-term care (or skilled-nursing) facilities
Medical equipment services
Office-based surgery
Psychiatric hospitals
Rehabilitation hospitals
Specialty settings certificate programs

Joint Commission Survey Process

Transitioned to unannounced survey process in 2006
Unannounced survey - an accredited organization will receive no notice
Initial surveys are announced unless required to be unannounced to meet deemed status requirements

Periodic Performance Review

Key component in continuous accreditation process
Hospitals incorporate standards as part of routine operations and ongoing quality improvement efforts
Hospitals required to submit an update to its PPR annually to Joint Commission

Joint Commission Documentation Standards for Hospitals - cont'd

CAMH divided into three sections
Patient-focused functions
Organizational functions
Structures with functions
Standards organized into functional chapters
Each chapter includes the following:
Standard
Rationale for the standard
Elements of performance

Management of Information (IM) section

affects health information management

Six categories of IM standards:

Planning
Confidentiality and security
Information management processes
Information-based decision making
Knowledge-based information
Patient-specific information

Additional CAMH standards relevant to health records

Ethics, rights, and responsibilities
Provision of care
Treatment and services
Medication management
Medical staff

Joint Commission Sentinel Events

Accredited hospitals required to implement systems to identify and address sentinel events
Sentinel event
Self-reporting is encouraged

Sentinel event

An unexpected occurrence involving death or serious physical or psychological injury or the risk thereof

Joint Commission ORYX

Integrates outcomes and other performance measure data into the accreditation process
Supports quality improvement efforts
Hospitals are required to collect and transmit data to the Joint Commission for a minimum of four core measure sets or a combination of applicable core measure sets and noncore measures

AOA - Healthcare Facilities Accreditation Program and Accreditation Process

Hospitals initiate process by submitting an application
Conducts on-site surveys at least every three years
Accreditation decision based on compliance with HFAP standards

Medical Staff Bylaws, Rules, and Regulations

Govern conduct of independent healthcare professionals who provide patient care services
Bylaws - similar to policies
Rules and regulations - similar to procedures that describe the specific activities to be carried out
Rules and regulations establish the medical staff's specific responsibilities for patient care and health record documentation

Medical Records Committee

Medical staff bylaws prescribe the duties and functions
Membership consists of
Physicians
President or designee
Nursing service representative
Director of HIM
Others to accomplish duties

...

Evaluating medical records using criteria developed and approved by medical board
Evaluating and recommending form and format of medical records
Monitoring medical records for promptness, adequacy, pertinence, and completeness
Referring identified deficiencies
Preparing reports as requested

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