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Documentation for Health Records

Chapter 8 Federal and State Requirements and Accreditation Guidelines
STUDY
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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