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Intro to HIM--Chapter 3

Terms in this set (93)

Electronic Health Record (EHR)
Health record available electronically allowing communication across providers and permitting real-time decision making.
What are the other terms used for EHR?
1. Electronic Medical Record (EMR)
2. Computer-based patient record (CPR)
Hybrid Record
Name given when transitioning from paper to electronic system and uses elements of both for patient care.
What are the 2 types of data that the heal record contains?
Clinical & Administrative
Clinical Data
Documents the patient's medical condition, diagnosis, procedures and treatment
Administrative Data
Includes demographic and financial information, consents & authorizations related to provision of care and handling of confidential patient information.
Standards
Statements of expected behavior or reference points against which structures, processes, outcomes can be measured.
Name the four main sources of standards for documentation
Facility Specific, Licensure requirements, certification standards & accreditation standards
Facility specific standards
Policies and procedures
Medical staff bylaws, rules, and regulations
All govern the practice of physicians within a specific organization
Licensure requirements
Regulations on how a healthcare
organization operates. Must comply with regulations to be licensed to provide healthcare
Each state is different
Certification Standards
Government reimbursement program standards that are applied to facilities that choose to participate in Medicare & Medicaid. Administered by CMS. Facilities are deemed certified if standards are met.
What are the 2 standards for certification by CMS called?
Conditions of Participation or Conditions for Coverage
Accreditation Standards
Public recognition through accreditation,
a voluntary process. Must meet patient care and other standards for high-quality care. Periodic surveys to determine compliance
with survey
Joint Commission
Accredits a number of different settings
Unannounced surveys
Annual submission of Periodic Performance Review
Standards for documentation
Prohibited abbreviation list
American Osteopathic Association (AOA)
Began with with accreditation of osteopathic
physician training programs
Accredits a variety of osteopathic organizations
Accreditation Association for Ambulatory Health Care (AAAHC)
Accredits ambulatory settings
Documentation standards emphasize summaries
for enhancing continuity of care
Commission on Accreditation of Rehabilitation Facilities (CARF)
Accredits rehabilitation programs and services
within other health care organizations
National Committee for Quality Assurance (NCQA)
Accredits managed care organizations, health
plans, and selected specialty areas
DNV (Det Norske Veritas)
Began hospital accreditation standards program in 2008. Referred to as the National Integrated Accreditation for Healthcare Organizations (NIAHO)
Acute Care Health Record
Basic acute-care content:
•Foundation for record content and practices in
health settings
•Based on documentation standards
Name the types of clinical data documented during a patient's hospital stay
*Medical and pertinent family history
*Physical examination report
*Attending docs dx and therapeutic orders
*Clinical observations by providers who care for pt
*Reports & results of diagnostic/therapeutic tests
*Reports of consulting physician
*Discharge summary
*Final instructions upon discharge
Medical History
Documents current complaints/symptoms and lists past medical, personal & family history
Name the elements included in medical history
Chief complaint, present illness, past medical history, social & personal history, family medical history, review of systems
Physical Examination report
Physicians assessment of the patients current health status and documents information on all major organ systems
Diagnostic/Therapeutic Orders
Physician orders, including admission & discharge order on every patient. Must be legible and include date & signature of doc.
Standing Orders
Orders physician has established as routine care for specific dx or procedure.
Verbal Orders
Physician's communicate orders verbally if staff rules allow. State law & staff rules specify which practitioners are allowed to accept and execute verbal orders.
Clinical Observations
Progress notes documented by physicians, nurses and other caregivers to create chronological report of the patients condition and response to treatment.
Physician Notes
Who can document is defined in medical staff
rules and regulations. (Attending, consulting, house medical staff, nurse, nutritionists, social workers, clinical therapists)
Specialty Physician notes
Notes specific to a certain treatment, ie pre & post anesthesia or summary statement of death (reason for admission, dx and course in hospital and what led to death)
Nursing (Allied Health) Notes & Assessments
Notes entered by nursing or allied health staff during course of stay. Admission nursing assessment
•Care plan
•Admission, progress, and discharge notes
•Vital signs
•Medications
•Chronological monitors
•Special interventions such as restraints
•Allied health assessments & Documentation of treatment by allied health professionals
Diagnostic Report Documentation
Lab tests, pathology, imaging reports, monitors & tracings of body functions
Procedure & Surgical Documentation
Any major procedure or surgery requires special documentation.
•Preoperative notes by anesthesiologist and surgeon
•Patient consent
•Anesthesia record
•Operative report
•Post-anesthesia (recovery room)
•Pathology report
Patient Consent Documentation
•Must be signed by patient
•Implied consent
•Expressed consent
•Physician must ensure patient understands procedure, alternative treatments, risks, complications, and benefits
Implied consent
Assumed when patient voluntarily submits to treatment
Expressed Consent
Spoken or written consent
Anesthesia Report
Notes preoperative medication
o Preanesthesia medications
o Anesthesia dose
o Method of administration
o Duration of administration
o Vital signs
o Preanesthesia
Procedure & Operative Reports
Describes surgical procedures performed on patient and include:
*Preop & Postop diagnosis
*Procedure performed
*All normal & abnormal findings
*Patient's medical condition before, during & after
*Estimated blood loss
*Description of any specimen removed
*Unique or unusual events during surgery
*Names of surgeons & assistants
*Date & Duration of surgery
Recovery Room Report
Documents monitoring of patient in recovery room. Includes
o Postanesthesia notes
o Patient's condition
o Nurses notes
o Vital signs
o Intravenous fluids
Pathology Report
Dictated by physician after examination of tissue. Includes
Description of tissue & full written report
o Macroscopic
o Microscopic
Consultation Report
Clinical opinion of a consulting physician (other than attending) Requested by primary or attending md, patient or family
Discharge Report
Concise account of the patient's illness, course of treatment, response to treatment and condition at time of discharge and follow-up care. Responsibility of attending.
Patient Instructions
Instructions given to patient at time of
discharge
Transfer Record
Brief overview of patient's acute stay along with current status, discharge and transfer order along with additional instructions.
Autopsy Report
Description of examination of patients body after death. Performed when there is a question surrounding death. Must have consent.
Obstetric Record
Prenatal record from physician office
Admission evaluation
Record of labor
Delivery record
Newborn Record
Birth history
Newborn identification
Physical exam
Nursing notes
Examples of Administrative Data
Demographics: Name, address
Financial: Insurance info, guarantors
Certificates: Birth or Death
Personal Property brought into hospital
Consents, Authorizations, Acknowledgements
*Consent to treat for routine, diagnostic procedures and medical care
*Notice of privacy practices
*Authorizations related to the release and
disclosure of confidential health information
Advance Directives
Written document that addresses care decisions if
a patient becomes incapacitated
o Durable power of attorney for healthcare
o Living will
Patient Self Determination Act (PSDA)
Went into effect in 1991and includes:
*Policies where patients can accept or refuse
medical treatment
*Patients notified of rights in making treatment decisions
*Documents if advance directive present
Acknowledgement of Patient's Rights
•Medicare Conditions of Participation give patients the right to
o know who is providing treatment
o confidentiality
o receive information about treatment
o refuse treatment
o participate in care planning
o be safe from abusive treatment
Emergency Care Documentation
*Patient ID (or why not obtained)
*Time and means of arrival
*Pertinent history of illness/injury including vital signs
*Emergency care given prior to and after arrival
*Presenting condition and initial assessment
*Diagnostic & therapeutic orders
*Clinical observations, including results of treatment
*Reports & results of procedures & tests
*Diagnostic impression
*Medications administered
*Conclusion, including final disposition, condition on discharge, instructions
*Documentation of cases when patient left AMA
Ambulatory Care locations
Documents care provided in physician office, clinics, HOD, health facilities and urgent care.
Ambulatory Care Documentation
*Registration forms
*Problem lists
*Medication lists
*Patient History
*H&P
*Progress notes
*Results of consultation
*Diagnostic test results
*Misc flow sheets (specialty specific, immunizations)
*Copies of past records
*Correspondence
*Consents to disclose information
*Advance Directives
OB/GYN Care Documentation
*Medical hx to include abuse/neglect or sexual practices
*Lab testing (Paps & Mammography)
*Additional labs needed for high risk groups
* STD, TB skin testing
Pediatric Care Documentation
*Birth History
*Nutritional History
*Personal, social & family history
*Growth & Development record
*Immunizations
*Visit documentation (well/sick)
Ambulatory Surgery Documentation (OR)
*Registration forms
*Patients Consent to surgical treatment
*Medical history & exam
*Pre-op studies
*Operative report
*Path report if tissue removed
*Allergic or abnormal drug reaction
*Record of anesthesia documentation
*Recovery room record
*Discharge diagnosis
*Records of any follow up calls
Long Term Care Facilities
*Skilled nursing (SNF)
*Nursing facilities (nursing homes, long-term care)
*Assisted living
What is the care plan for skilled nursing facilities?
*Resident assessment instrument (RAI)
*RAI's used to determine Med B reimbursement
What is the RAI based on?
Minimum Data Set (MDS) for Long-term care
What does the RAI framework include?
MDS, Triggers, utilization guidelines & care area assessments (CAAs)
What are records based on for long term facilities?
Ongoing assessments and re-assessments based on care plan developed by interdisciplinary team. Care plan updated regularly during patient stay.
Long Term Care Documentation
*Registration forms including identification data
*Personal property list (includes furniture & electron)
*H&P and hospital records
*Advance directives, bill of rights, legal records
*Clinical assessment
*RAi/MDS and care plan
*Physician orders
*Physician progress note/consultation
*Nursing notes
*Rehab notes
*Social services, nutritional services, activities documentation
*Medication and records of monitors (includes restraints)
*Lab, radiology and special reports
*Discharge or transfer documentation
What is record thinning?
Process if paper records exist where selected material is removed and filed elsewhere according to facility guidelines. Material removed must remain accessible.
What does home health agencies provide?
Medical and non-medical services in the patient's home or place of residence.
What is the standardized patient assessment instrument used by Medicare certified home health agencies?
Outcomes and Assessment Information Set (OASIS)
*most recent veris is OASIS-C: submitted electronically to state health dept then to CMS
Home Healthcare Documentation
*Patient identification data & service agreement
*Certification & plan of treatment
*Physician's orders
*Documentation by each discipline involved in home care
*Patient assessment (OASIS-C), plan of care & case conference notes
*Consents & other legal documents
*Referral or transfer information from other facilities
*Discharge summaries
What is hospice care?
Provides palliative care to terminally ill patients and supportive service to patient and family. Focuses on symptom management and patient comfort.
Where can hospice care be provided?
Patient's home, hospitals, long-term care facilities & free standing facilities
Hospice Care Documentation
*Patient ID
*Physician & Emergency contacts
*Diagnosis & prognosis
*Assessments
*Care plans (updated every 30 days) and notes
*Bereavement documentation
Where can behavioral health be provided?
Inpatient hospitals, outpatient clinics, physician's offices, rehab programs, long-term care facilities, & community mental health programs
*Documentation varies by setting
Inpatient Behavioral Healthcare Documentation
*Registration forms & patient ID
*Referral info
*Legal status
*Consents for admission, treatment, eval & aftercare
*Admitting psychiatric dx
*Patient assessment (includes complaints of others, as well as patient)
*Individualized treatment plan & updates
*Reports of treatment, evals, and exams
*Multidisciplinary progress notes
*Note on unusual occurrences (complications, accidents/injuries,death, risky procedures, restraints, seclusion
*Correspondence including letters and notes of phone conversations
*Discharge or termination summary
*Individualized aftercare or post-treatment plan
Rehabilitation Services Documentation
*Patient ID
*Pertinent history, including functional history
*Dx of disability/functional dx
*Rehab problems, goals and prognosis
*Reports of assessments and program plans
*Reports from referring sources and service referrals
*Reports from outside consults, labs, radiology, orthotic and prosthetic services
*Designation of manager for patients program
*Evidence of patient's or family's participation in decision making
*Evaluation reports from each service
*Reports of staff conferences
*Progress reports
*Correspondence related to patient
*Release forms
*Discharge summary
*Follow up reports
Documentation of Services in Correctional Facilities
*Baseline info including H&P, chest x-ray, labs, dental & psych exam, progress notes, orders, meds, care provided & other assessments
End Stage Renal Disease Documentation
*Dialysis provided to patients
*Patient rights
*Interdisciplinary patient assessment
*Plan of care
*Progress Notes
*Labs
*Discharge summary
*Consents
Name the areas of special emphasis for ESRD
Nutrition, anemia, vascular access, transplant, rehab status, social service interventions and dialysis dosages.
Basic Documentation Principles
•Policies to ensure uniformity of health record
content and format
•Systematic organization to facilitate data
retrieval and compilation
•Policies regarding who can document in
health record (authorized individuals)
•Policies and medical staff bylaws defining who
can receive/transcribe verbal order
•Entries are documented at the time service is provided
•Authors of entries clearly identified
•Only abbreviations and symbols approved by
organization and medical staff rules and regulations used in the record
•All entries are permanent
•Error correction
What do the principles of basic documentation practices address?
uniformity, accuracy, completeness, legibility, authenticity, timeliness, frequency and format of health record entries
List the steps to correct an error in a paper record
*Drawing a single line in ink through incorrect entry
*Printing word "error" at top of entry along with
signature (or initials)
*Documenting date, time and reason for change
*Recording correct information
*Retaining legibility of erroneous recording
*Labeling late entries as such
Goals of Clinical Documentation Improvement (CDI) programs
*Identify & clarify missing, conflicting or nonspecific physician info related to dx & procedures
*Support accurate diagnostic & procedural coding leading to appropriate reimbursement
*Record completion during course of care
*Improve communication between provider & other members of health care team
*Provide education
*Improve documentation to reflect quality & outcome scores
*Improve coders' clinical knowledge
List steps of CDI process
•Review record documentation day after patient admission
•Record findings on a worksheet (patient identification, working diagnostic/procedural codes, and such)
•Query physician (or other providers) if questions arise
•Receive response with documentation reflected on the query form or within the health care record
•Follow-up and repeat the process periodically until
patient discharge
•Perform final coding and DRG assignment
What are the three formats of paper based records?
1. Source-oriented
2. Problem-oriented
3. Integrated
Source-oriented record
Documents are grouped together according to their point of origin. (ex lab records grouped together)
*Can be in chronological or revers chronological order
Problem-oriented record
Documents itemized list of patients past & present social, psychological and medical problems.
*Each problem is identified by a unique number
What are the 4 major sections of problem-oriented record?
*Problem list
*Database
*Initial Care Plan
*Progress Notes
In addition to the problem list, what other components are included in problem-oriented record?
*Chief complaint
*Present illness
*Social history
*Medical history
*Physical exam
*Diagnostic test results
True or False: Patient plans & progress notes are numbered with unique number assigned to problem
True
SOAP Format
Subjective, objective, assessment, plan
Integrated Health Record
Documentation from various sources is intermingled and follows strict chronological date order
Definition of Electronic Medical Record (EMR)
Electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within 1 healthcare organization
Definition of Electronic Health Record (EHR)
Electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and can be created, managed and consulted by authorized clinicians and staff across more than one health care organization.
Name the Core Capabilities of EHR
*Health information & data
*Results management
*Order entry and management
*Decision support
*Electronic communication & connectivity
*Patient support
*Administrative processes
*Reporting & population health management
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