Medical Records Documentation

Who is responsible to order Laboratory Test?

All tests must be ordered by the patient's physician(s).

What are some examples of common ancillary documents and reports?

Laboratory Reports Pathology Reports Radiography Reports EKG Reports Physical Therapy Reports Dietary Reports Social Services Reports

Adhere to ethical standards for health information management and coding professionals

Medical ethics is using reason and logic to deal with situations concerning life, death, and the continuum between the two. It also deals with regulating the behavior of the health care professional

List the various types of documentation written by nurses and explain their content.

Nurses Notes, Flow charts, Graphic Vital Sign Records, Intake and Output records(I&O) Nurses Notes contain; Documentation that reflects the patient's condition and progress in objective, behavioral terms.

Explain Joint Commission Standards related to restrain patients. Who would you expect to be documenting that monitoring?

Patients in restraints are monitored at a minimum, every two hours. Each episode of restraint use is documented in the patient's medical record, consistent with organization policy(ies) and procedure(s). Nurses

Discuss the responsibility of physicians for the medical record

Physician has the major or final responsibility for individual medical record

Which part of medical history documents the nature and duration of the symptoms that caused a patient to seek medical attention as stated in that patient's own words?

Present illness ( history of present illness)

privacy

Privacy is your right to keep things to yourself, your ability not to have to disclose private things about yourself.

Medication Administration Record (MAR)

Contains documentation of all drugs ordered and administered including the date, time, name of drug, dose, route (orally, topically, injection, inhalation, infusion, etc), and who administered the drug. Documentation of missed doses and the reason is also documented.

Explain the purpose and content of anesthesia assessments and reports

Content - Most anesthesia forms used by hospitals contain areas to document pre-anesthesia evaluations and pre-anesthesia medications (such as valium or other medications used to relax the patient)as well as the administration of anesthetics, medications (including type, route, amount), fluids and blood products during the procedure and the monitoring of the patient's status. An anesthesia record is not required for the administration of local anesthetics.

Name five items you would expect to be documentated on the initial Nursing Assessment.

Current & past illnesses, know drug allergies, current medication date, time, and method of admission, and current condition, symptoms, vital signs, weight.

The SOAP format is method for documenting ____

Progress notes of POMR

Name two main forms where you would expect to find documentation of the patient's final diagnosis

Face sheet & Discharge summary

Under what circumstances may a final progress note be substituted for a discharge summary ?

For normal newborns with uncomplicated deliveries, or for patients hospitalized for less than 48 hours with only minor problems, a progress note may substitute for the clinical resume.

general consent?

For use or disclosure of information for treatment, payment, and healthcare operations most be obtained before treatment is provided.

Explain format for Dietitian's Documentation and who authenticates that document.

Format - Nutritional assessment forms and narrative nutritional progress notes. Responsibility - Qualified dietitians document and authenticate entries.

List the limitations electronic records health records

Further maturation needed in some technologies, standards most be developed, tested. Exchange of health care data.

Who is responsible for completing postoperative reports

Generally is completed by the nursing staff and signed by the nurse in charge of the unit but may be signed by the physician or both the nurse and the physician. A post-anesthesia note signed by the anesthesiologist/nurse anesthetist is required within 24 hours after the surgery.

Discuss in detail the HIPAA Privacy Rule

HIPAA, a federal law passed in 1996 included administrative simplification requirements to 1) standardize electronic submission of administrative and financial transactions and 2) to protect the security and privacy of transmitted information.

Discuss the responsibility of CEO for the medical record

Hospital Administrator (CEO) is responsible to provide health information management department that is equipped and staffed, also enforces Medical Record regulations/policies/standards within the hospital and HIM department

Explain the concept of Need to Know"

If the physician or nurse is not involved in the patient's evaluation or treatment or in the administrative function such as quality improvement involving the medical record, then he/she is not entitled to see the record.

Social Services/Case Management content:

Includes documentation of the background and social information of the patient, as well as social problems such as family or personal problems identified by the patient or family such as problems with housing or access to healthcare services. Social service notes typically include a plan of action, progress notes and a discharge note.

The number of ligatures, sutures, packs, drains, and sponges used and specimens removed would be found in the ______?

Intra-operatives reports

Authorization

Is required for the use or disclosure of protected health record for purposes other than treatment, payments or operations. E.g psychotherapy notes.

Define a medical record

Is the repository of all data of an individual's health status, it contains the who, what, where, when, why, and how-all the relevant facts of the patient's illnesses, care, and treatment

What is Joint Commission time requirements for post-anesthesia evaluation for an inpatient?

JC requires at least one post-anesthesia visit describing presence or absence of post-anesthesia complications within 24hrs of surgery.

Explain Joint Commission and Medicare standards related to Social Services/Case Management.

Joint Commission - "when appropriate the patient is educated about available community resources." Medicare COP - 482.43 Condition of participation:Discharge planning. The hospital must have in effect a discharge planning process that applies to all patients. The hospital's policies and procedures must be specified in writing. (a) Standard: Identification of patients in need of discharge planning. The hospital must identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning. (b) Standard: Discharge planning evaluation. (1) The hospital must provide a discharge planning evaluation to the patients identified in paragraph (a) o f this section, and to other patients upon the patient's request, the request of a person acting on the patient's behalf,or the request of the physician. (2) A registered nurse, social worker,or other appropriately qualified personnel must develop, or supervise the development of, the evaluation. (3) The discharge planning evaluation must include an evaluation of the likelihood of a patient needing post- hospital services and of the availability of the services. (4) The discharge planning evaluation must include an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital. (5) The hospital personnel must complete the evaluation on a timely basis so that appropriate arrangements for post-hospital care are made before discharge,and to avoid unnecessary delays in discharge. (c) Standard: Discharge plan. (1) A registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise the development of, a discharge plan if the discharge planning evaluation indicates a need for a discharge plan.

Joint Commission and Medicare COP standards for Preoperative reports

Joint commission "Before surgery, the patient's physical examination and medical history, any indicated diagnostic tests, and a preoperative diagnosis are completed and recorded in the patient's medical record." Medicare COP "(1) There must be a complete history and physical work-up in the chart of every patient prior to surgery, except in emergencies. If this has been dictated, but not yet recorded in the patient's chart, there must be a statement to that effect and an admission note in the chart by the practitioner who admitted the patient.

Pathology report format

The report is almost always dictated by the pathologist and then transcribed.

Care plan

The specific goals in the treatment of an individual patient, amended as the patient's condition requires, and the assessment of the outcomes of care; servers as the primary source for ongoing documentation of the resident's care, condition and needs.

Who Do the Standards Apply To?

The standards apply to covered entities which are defined as health plans healthcare clearinghouses providers

Name two forms in which you would find documentation that the physician's order had been carried out.

Therapeutic services, discharge order, ancillary medical services, special orders, nurses notes, MAR

Occupational, Physical, Speech Therapy and Other Rehabilitation Services

Therapists notes regarding assessment and treatment plans designed to restore function. Notes include a plan of care, documentation of objective and goal-oriented services and the patient's response to treatment.

Laboratory Reports

These are the reports of findings of various tests performed on body materials, fluids and tissues.

Responsibility for Occupational, Physical, Speech Therapy and Other Rehabilitation Services

These services must be ordered by the physician. Therapists must authenticate their own notes.

Discuss the responsibility of medical staff for the medical record

They review record rules, regulations policies, and standards is responsible for the maintenance, and completion and clinical pertinence.

Medicare requires that medical records be completed within what time frame?

They should be completed with in 30 days of discharge.

Imaging Report

This is a report of the interpretation of diagnostic x-Rays ordered by the physician

Radiology Reports

This is a report of the interpretation of diagnostic x-rays ordered by the patient's physician.

List the data elements that must be included in pathology reports

This report contains a description of gross (macroscopic)findings of specimens received. A description of microscopic findings may also be performed. Additionally the report gives a pathological diagnosis based upon the findings.

The HIPAA privacy rule defines PHI as

Protected Health Information (PHI) protects a patient's health information in any form including paper, electronic or oral form.

Bar Code Medication Administration (BC-MAR)

System that identify the right patient and right drug to be given at the right time, in the right dose, and via the right route

Case management

1. The ongoing, concurrent review performed by clinical professionals to ensure the necessity and effectivenes of the clinical services being provided to a patient. 2. A process that integrates and coordinates patient care over time and across multiple sites and providers, especially in complex and high-cost cases 3. The process of developing a specific care plan foa a patient that seres as a communication tool to improve quality of care and reduce cost.

Define Professionalism

: the skill, good judgment, and polite behavior that is expected from a person who is trained to do a job well

Define Administrative Information systems

A category of healthcare information systems that supports human resources management, financial management, executive decision support, and other business-related functions.

Differentiate between personal and impersonal uses of a medical record

A personal use of the medical record occurs whenever the identity of the individual is revealed or important to the use of the medical record e.g request of the patient's inmunization record by a school. An impersonal use of the medical record is an instant when the identity of the patient is not revealed or not necessary for the intented use.

Patient Assessment Instrument (PAI)

A standardized tool used to evaluate the patient's condition after admission to, and at discharge from, the healthcare facility.

Define Pathology report

A type of health record or documentation that describes the results of a microscopic and macroscopic evaluation of a specimen removed or expelled during a surgical procedure.

List key aspects of HITECH that relate to Privacy

ARRA has several provisions that extend HIPAA privacy, security, and administrative requirements to business associates (BAs). In addition there are new provisions for HIPAA-covered entities and BAs, as well as provisions for those not considered HIPAA-covered. Breach requirements (identification and notification) are established both for HIPAA-covered entities and non-HIPAA-covered entities, essentially any organization holding personal health information. Restrictions are further established on the sales of health information. A new accounting requirement is established for disclosure related to treatment, payment, and operations. New access requirements are established for individuals related to healthcare information in electronic format. New conditions are instituted for marketing and fund raising functions. Personal health record information with non-HIPAA entities is now protected. Use of de-identified data and minimum necessary data will be addressed. Enforcement is improved and penalties are increased.

Demographic data, socioeconomic data, financial data and consents are which part of the health record

Administrative

According to the Conditions of Participation for hospital what healthcare professional(s) is responsible for developing or supervising the development of the discharge planning evaluation?

As per Medicare COP a registered nurse, social worker, or other appropriately qualified personnel most develop or supervise the development of the evaluation

Identify the ancillary functions of the health record.

Assist the physician in diagnosing and threatening the patient

Discuss the responsibility of HIM Department for the medical record

Assume responsibility for the health record is maintained, stored, and able for retrieval, confidentiality, data, security integrity, access, performing coding, classification managing paper and non paper patient information and organization.

Sometimes a physician needs to ask another physician for an opinion regarding the care of a patient. The physician whom he asks is referred as the______

Attending physician

Discuss the purposes of health records

Communication; among various health care professionals serving the patient Basis for planning; individuals care Documentary evidence; of the course of the patient's illness & treatment Evaluation of quality of care; rendered to the patient Protecting legal interest of the patient, hospital, physician Research and evaluation; providing the clinical data used in research and education Administration; necessary for accreditation, licensing, planning etc Billing and reimbursement; serves as an information for developing sustaining the billing and claim for payment of healthcare services

List the data elements that must be included in Radiology Reports

Content includes patient identification information, x-ray number, name of x-ray procedure performed, date performed, reason for x-ray examination, as well as the interpretation and authentication by the radiologist. Interpretation typically includes a description of findings and an impression.

Define contextual normal expected in Healthcare Organizations

Contextual norms are the acceptable behaviors and attitudes of the professionals who work in a particular environment. Often, these behaviors are supportive of safe work practices and contribute to effective teamwork as well.

Distinguish between the terms information and data.

Data is non-interpreted items represent the basic facts about people measurements, conditions etcetera e.g text Information represent meaning e.g reports, graphs

Give an example of an impersonal use of a health record

For example the statistical, research and historical and the name of the patient is not important.

Explain Format for Preoperative Report

Generally forms contain a combination of checklist items and fill-in documentation.

Discuss the responsibility of Governing Board for the medical record

Governing board has a GENERAL responsibility, has the final management responsibilities e.g selection of an efficient staff.

Postoperative documentation

Includes documentation of the patient's level of consciousness when entering and leaving unit, as well as vitals signs and the status of infusions, dressings, tubes, catheters and drains.

Explain Joint Commission and Medicare standards related to Nutritional Documentation

Joint Commission - "When warranted by the patient's need, nutritional status is assessed." "When appropriate, the patient is educated about diet and nutrition, including potential drug-food interactions." "... authorized individuals prescribe or order food and nutritional products in a timely manner". Medicare COP - 482.28 Condition of participation:Food and dietetic services. (b) Standard: Diets. Menus must meet the needs of the patients. (1) Therapeutic diets must be prescribed by the practitioner or practitioners responsible for the care of the patients. (2) Nutritional needs must be met in accordance with recognized dietary practices and in accordance with orders of the practitioner or practitioners responsible for the care of the patients.

Postoperative report format

May be either a separate form or may be combined with the anesthesia record.

Occupational, Physical, Speech Therapy and Other Rehabilitation Services Format

May be either forms that are filled in or an appropriately labeled record for therapist notes.

Responsibility for EKG Reports

Must be ordered by the physician. Tracing is "read" and authenticated by a cardiologist.

A patient has had an appendectomy and has been transferred from post-anesthesia Care Unit back to their regular room. The surgeon has ordered that the surgical would be cleaned three times per day and observed for signs of infection. On what form would you look to confirm that the order had been carried out

Nurses progress note

What is the JC timeline requirement for the completion of nursing assessment

Nursing assessment must be completed within 24 hours of admission

Nurse's notes, Graphic Chart, Intake, and Output Record (I&Os) are examples of what type of the clinical documentation

Nursing documents & reports

On which medical record document would you expect to find ALL of the following documented.? Preoperative Diagnosis Postoperative Diagnosis Specimens Removed Description of findings

Operative Report

Describe the purpose of developing health record policies and procedures.

Quality of care for patients in every healthcare environment

Differentiate between the following medical record formats, including advantages and disadvantages. Source-oriented Integrated Problem-oriented

Source oriented: conventional is the most common format, is arranged by department, e.g all progress notes are together Advantages; easy to compare related tests, individual Pages can be located. Disadvantages; difficult to identify the nature of the patient's most recent treatment. Integrated: the record is arranged in strict chronological order. Advantages; allows healthcare professionals to see a progression of the patient's care. Disadvantages; comparing of tests is more difficult role, Problem-oriented; emphasizes following the course of treatment for a particular problem from start to finish. Has 4 parts database, problem list, initial plans, progress note(soap) Disadvantages; time consuming

List users of health records

The Patient The provider The healthcare Delivery system

List the limitations hybrid records health records

The challenging when it comes to locating all components of a health record, are costly due to duplicate processes and maintenance.

What is the difference between a Review of Systems and an Inventory of Body Systems?

The difference between ROS and IBS is that the review of systems is the symptoms the patient is experiencing, and the Inventory of systems is the assessment of the patient's condition, through physical examination by a physician or other authorized healthcare practitioner.

Who authenticates the Pathology report

The pathologist is responsible for authenticating the report.

Anesthesia documentation

This report documents all pre-operative and intra-operative medications, as well as monitoring of vital signs during the procedure and all anesthetic procedures.

What is Medicare's time requirements for post-anesthesia evaluation for an inpatient?

Within 48 hrs after surgery

Autopsy Report

Written documentation of the findings from a postmortem pathological examination.

Define the following key term: Autopsy report

Written documentation of the findings from a postmortem pathological examination.

A patient is admitted for hip replacement. Three days prior to admission the attending physician saw the patient in her office and performed a History and Physical Examination. The physician placed a copy of his report in the patient's medical record. According to JC does that copy of the office H & P meeting JC requirements for the admission . Why or why not.?

Yes, joint commission is up to 30 days prior admission.

What's Protected? With HIPAA

all medical records and other individually identifiable health information in any form or medium Health information is defined as any information, whether oral or recorded in any form or medium, that: Is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.

security.

is the activity of protecting your personal information.

Joint Commission Requirements for Nursing assessment

must be completed within 24 hours of admission

Discuss the importance of dress, deportment, demeanor and grooming.

our appearance contributes to how people perceive you as a professional. Appropriate dress and grooming are also important components of being a professional in the healthcare environment. As part of professional demeanor, good grooming and appropriate dress communicate to others that you respect yourself, them, and the organization. They also contribute to your being treated with respect by your co-workers.

What is the procedure if transcription delays occur with OP

physicians should write a comprehensive operative note in the medical record for continuity of care purposes.

List data elements included in Preoperative Reports

pre-operative forms are used, content usually includes checklists of things required prior to surgery such as a H&P, informed consent, results of ordered lab work. The record may also be used to record a pre-operative nursing assessment and pre-procedure medications.

MAR format

the initials of the person administering the dosage are entered. At the bottom of the page, a legend is generally made to identify the full name and credentials corresponding to each set of initials used. It can be computer generated. Three columns mark the three nursing shifts. Times for administration are indicated in the column for the appropriate shift, followed by a line.

The federal rule preempts (or takes precedence over) any state regulations except

the state law is more stringent the state law related to the reporting of disease/injury, child abuse, birth, or death or when it relates to public health surveillance, investigation or intervention the state law requires a health plan to report or provide access to information for the purpose of audits, program monitoring evaluation or licensing or certification of facilities or individuals the state has received approval from DHHS for an exception

Preoperative anesthesia evaluation

usually includes checklists of things required prior to surgery such as a H&P, informed consent, results of ordered lab work. The record may also be used to record a pre-operative nursing assessment and pre-procedure medications.

Requirements for postOperative Reports as per Joint Commission and Medicare COP

"Postoperative documentation records the patient's vital signs and level of consciousness; medications (including intravenous fluids), blood, and blood components; any unusual events or postoperative complications; and management of such events." "Postoperative documentation records the patient's discharge from the postanesthesia care area by the responsible licensed independent practitioner or according to discharge criteria." "Compliance with discharge criteria is full documented in the medical record" "Postoperative documentation records the name of the licensed independent practitioner responsible for discharge." Joint Commission also requires at least one post-anesthesia visit describing presence or absence of post-anesthesia complications within 24 hours of the surgery. This is documentation beyond that of the operative and recovery room documentation. It might be recorded by a number of individuals such as the attending physician, surgeon or anesthesiologist. This note can be documented in a variety of locations such as in the progress notes, recovery room record or anesthesia record. Medicare COP - 482.52 Condition of participation: Anesthesia services. -(b) Standard: Delivery of services. "(3) With respect to inpatients, a postanesthesia evaluation must be completed and documented by an individual qualified to administer anesthesia as specified in paragraph (a) of this section within 48 hours after surgery. (4) With respect to outpatients, a postanesthesia evaluation for proper anesthesia recovery performed in accordance with policies and procedures approved by the medical staff."

Advance Directive

A legal, written document that describes the patient's preferences regarding future healthcare or stipulates the person who is authorized to make medical decision in the event the patient is incapable of communicating his or her preferences.

Clinical pathway

A tool designated to coordinate multidisciplinary care planning for specific diagnoses and treatments.

Recovery Room Record

A type of health record documentation used by nurses to document the patient's reaction to anesthesia and condition after surgery aka Recovery Room Report

Other names for postoperative reports

AKA Post-Anesthesia Record or Recovery Room Record.

Admission/ registration Form, Routine consent for Diagnosis and treatment, and special consents are examples of

Administrative Data

What are the two main types of data of a Health Record?

Administrative and clinical

List the data elements that must be included in the Autopsy Report

Contains the findings of macroscopic and microscopic examinations of the body after death. The autopsy report contains a summary of patient's history and treatment, a report of gross and microscopic findings and the provisional and final diagnoses.

Explain the function and content of discharge summaries

Content - A summary of the patient's hospitalization that typically includes: Reason for hospitalization Hospital Course - chronological narrative of significant findings from exams and tests Procedures performed and treatments Patient's response Condition on discharge - in non-ambiguous terms. Statements like "improved" or "better" are discouraged. The physician should document how the patient is improved. Discharge instructions: In terms of follow up, activity level, diet, medication, etc. Final diagnoses are almost always listed in the discharge summary. The discharge summary function as an information to other caregivers and facilitates continuity of care. For patients discharged to ambulatory (outpatient) care, the clinical resume summarizes previously levels of care.

List the data elements that must be included in imaging reports

Content - This is a report of the interpretation of diagnostic x-rays ordered by the patient's physician. Content includes patient identification information, x-ray number, name of x-ray procedure performed, date performed, reason for x-ray examination, as well as the interpretation and authentication by the radiologist. Interpretation typically includes a description of findings and an impression.

Describe the types of services covered in physicians' orders

Date and time of the order, signature of the physician who order the treatment and who picked up the order

EKG Reports

EKG (electrocardiogram) reports are reports of the electrical activity of the heart. The report, in addition to patient identification includes a tracing as well as measurements and an interpretation

EKG reports format

EKG tracing are printed either directly on strips which are then mounted on a mounting sheet or are printed directly on a full-sheet of paper. The latter is more common now. Most EKG machines are now capable of printing a machine-interpretation of the results. These machine interpretations must be confirmed by a cardiologist

Format and Responsibility of Autopsy Report

Format - The report is dictated by the pathologist and then transcribed. Responsibility - The pathologist performing the autopsy is responsible for dictating and authenticating the transcribed report. Authorization for the autopsy must be obtained from the patient's family unless the case is a coroner's case (more about this in your legal aspects and health statistics courses).

Radiology reports Format

Format - X-ray films are reviewed and interpreted by a Radiologist who dictates the interpretation. This dictation is typically transcribed by a medical transcriptionist. Voice recognition technology is being used by some Radiology Departments to transcribe the interpretation. Some hospitals use a format in which the upper portion of the report form serves as the request from the ordering physician and the lower portion is radiologist's report of findings and impression.

What are some examples of common medical documentation and reports?

History and Physical Examination (H&P), Progress Notes, Operative Reports, Physician Orders, Discharge Summary (DS)

Explain JC and Medicare requirements for Admission/Discharge Record aka Face sheet

IM 7.2 The medical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers.

Explain the function of nurses documentation

Is an important communication tool that allows the physician to see what has happened to the patient in his/her absence. They provide proof that the physician's orders were carried out and documentation of the patient's response.

Intraoperative documentation

Is one of many forms to document data during the operative procedure. Is a Nurses Worksheet used to record the opening and closing counts of instruments and materials used during the operative episode. Counts of items used during the procedures are compared to closing counts to ensure that no materials or instruments are inadvertently left inside the patient.

Explain Joint Commission and Medicare standards related to ancillary service documentation

Joint Commission - "... the medical record contains very specific data including all diagnostic and therapeutic procedures and test results" Other - AKA X-ray report. The films and a copy of the report are filed in the Radiology Department. The results of other imaging examinations such as MRIs and ultrasounds contain similar content and format. Therapeutic radiology (radiation used for the treatment of cancer) consists of a summary of radiotherapy (use of cobalt, radium and radioactive isotopes)given. At the end of the treatment series it is signed by radiologist and made a part of the medical record.

List the data elements that must be included in laboratory reports

It should contain the patient identification information, the name of the test, test date, time in and out of laboratory, test result. The report should also indicate the pathologist in charge of the laboratory. Reports usually also contain the normal value range for each test when appropriate. Often results that are out-of-range are marked in some way such as with an asterisk to call attention to the result. When results are performed by a technologist rather than automatic results reporting by a computer and laboratory equipment, the technologist performing the test is indicated (often with the use of initials or code number). Certain special tests may not be performed by the hospital and are sent out to another lab. These results become part of the patient's medical record and must contain the name of the laboratory performing the test.

Explain Joint commission and Medicare Standards related to Laboratory Reports

Joint Commission - "... the medical record contains very specific data including all diagnostic and therapeutic procedures and test results" Medicare COP -... Other - Medical staff rules and regulations may require certain tests such as CBC and UA for all patients unless specified otherwise by the physician.

Explain Joint Commission and Medicare standards related to Autopsy Report

Joint Commission - "When an autopsy is performed, provisional anatomic diagnoses are recorded in the medical record within three days, and the complete protocol is included in the record within 60 days, unless the medical staff establishes exceptions for special studies." Note: Some of the microscopic tests used in autopsy reports such as toxicology testing take a considerable amount of time to perform, therefore it is not unusual for the final autopsy report to be completed in 6-8 weeks. "The medical staff shall attempt to secure autopsies in all cases of unusual deaths and of medical-legal and educational interest. The mechanism for documenting permission to perform an autopsy must be defined. There must be a system for notifying the medical staff, and specifically the attending practitioner, when an autopsy is being performed." Other - AKA post mortem examination or necropsy.

Explain Joint Commission and Medicare standards related to Medication Administration a Record

Joint Commission - "... the medical record contains: every medication ordered or prescribed for an inpatient every medication dispensed to an ambulatory patient or an inpatient on discharge every dose of medication administered and any adverse drug reaction" Medicare COP 482.23 Condition of participation:Nursing services.(c) Standard: Preparation and administration of drugs. Drugs and biologicals must be prepared and administered in accordance with Federal and State Laws, the orders of the practitioner orpractitioners responsible for the patient'scare as specified under482.12(c), and accepted standards ofpractice. (1) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. (2) With the exception of influenza and pneumococcal polysaccharide vaccines,which may be administered per physician-approved hospital policy after an assessment of contraindications, orders for drugs and biologicals must be documented and signed by a practitioner who is authorized to write orders by hospital policy and in accordance with State law, and who is responsible for the care of the patient as specified under 482.12(c). (i) If verbal orders are used, they are to be used infrequently. (ii) When verbal orders are used, they must only be accepted by persons who are authorized to do so by hospital policy and procedures consistent withFederal and State law.

Cite Joint Commission and Medicare standards for documentation of Discharge Summaries

Joint Commission - A concise clinical resume included in the medical record at discharge provides important information to other caregivers and facilitates continuity of care. For patients discharged to ambulatory (outpatient) care, the clinical resume summarizes previously levels of care. The discharge summary contains the following information. The reason for hospitalization Significant findings Procedures performed and treatment rendered The patient's condition at discharge Instructions to the patient and family, if any For normal newborns with uncomplicated deliveries, or for patients hospitalized for less than 48 hours with only minor problems, a progress note may substitute for the clinical resume. The medical improves the quality of healthcare by insuring that the best information is available to make any healthcare decision. Health information management professionals manage healthcare data and information resources. The profession encompasses services in planning, collecting, aggregating, analyzing, and disseminating individual patient and aggregate clinical data. It serves the healthcare industry including: patient care organizations, payers, research and policy agencies, and other healthcare-related industries. defines what problems and interventions may be considered minor. The progress note may be handwritten. It documents the patient's condition at discharge, discharge instructions, and follow up care required. When a patient is transferred within the same organization from one level of care to another (for example, from the hospital to residential care), and the caregivers change, a transfer summary may be substituted for the clinical resume. A transfer summary briefly describes the patient's condition at time of transfer, and the reason for the transfer. When the caregivers remain the same, a progress note may suffice. Medicare COP - 428.24 Medical Record Services (c)Standard: Content of record within 30 days following discharge. (2) All records must document the following, as appropriate: (vii) Discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care. (viii) Final diagnosis with completion of medical records within 30 days following discharge.

Explain Joint Commission and Medicare standards related to nursing documentation

Joint Commission - Nursing documentation contributes to many of Joint Commission's documentation requirements including: progress notes made by the medical staff and other authorized individuals clinical observations the patient's response to care discharge instructions to the patient and family Some specific requirements that nursing documentation needs to comply with or contributes to meeting the standard are: Nursing assessment must be completed within 24 hours of admission Patients' learning needs, abilities, preferences and readiness to learn is assessed. The assessment considers cultural beliefs, religious beliefs, barriers to learning (i.e., emotional, physical, cognitive) When called for by the age of the patient and the length of stay, school-age children are given the opportunity to continue their schooling. The patient is educated about the safe and effective use of medications The patient is educated about diet and nutrition, including potential drug-food interactions The patient is educated about rehabilitation techniques. The patient is educated about personal hygiene and grooming. The following is assessed for each patient: physical status, psychological status, social status Need for discharge planning is determined. Monitoring of a medication's effect on the patient includes an assessment based on collective observations, including the patient's own perceptions of its effect. Medicare COP - A registered nurse must supervise and evaluate the nursing care for each patient. The medical record must contain information to justify admission and continued care. All records must document the following, as appropriate: (vi) All practitioners' orders, nursingnotes, reports of treatment, medication records, radiology, and laboratory reports,and vital signs and other information necessary to monitor the patient'scondition. 482.43 Condition of participation:Discharge planning. The hospital must have in effect a discharge planning process that applies to all patients. The hospital's policies and procedures must be specified in writing. (a) Standard: Identification of patients in need of discharge planning. The hospital must identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning. (b) Standard: Discharge planning evaluation. (1) The hospital must provide a discharge planning evaluation to the patients identified in paragraph (a) of this section, and to other patients upon the patient's request, the request of a person acting on the patient's behalf,or the request of the physician. (2) A registered nurse, social worker,or other appropriately qualified personnel must develop, or supervise the development of, the evaluation. (3) The discharge planning evaluation must include an evaluation of the likelihood of a patient needing post- hospital services and of the availability of the services. (4) The discharge planning evaluation must include an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital. (5) The hospital personnel must complete the evaluation on a timely basis so that appropriate arrangements for post-hospital care are made before discharge,and to avoid unnecessary delays in discharge. (6) The hospital must include the discharge planning evaluation in the patient'smedical record for use in establishing an appropriate discharge plan and must discuss the results of the evaluation with the patient or individual acting on his or her behalf. (c) Standard: Discharge plan. (1) A registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise the development of, a discharge plan if the discharge planning evaluation indicates a need for a discharge plan.

Cite Joint Commission and Medicare standards for documentation of History and Physical Examination,

Joint Commission - Requires: Medical History including the chief complaint; details of the present illness; relevant past, social, and family histories (appropriate to the patient's age); and a review of body systems. required usually within 24 hours of admission and always before surgery is performed. if recorded within 30 days prior to admission to the hospital, a legible copy may be included in the health record and any interim changes recorded at time of admission. if patient readmitted within 30 days for same or related condition, an interval H&P explaining changed may be used. Medicare COP - 482.24 (c)(2) All records must document the following, as appropriate: (i)"Evidence of a physical examination, including a health history, performed no more than 7 days prior to admission or within 48 hours after admission." Other - The facilities Medical Staff Rules and Regulations will state which individuals (such as medical students, interns, etc.) require countersigning of reports by the

Explain Joint Commission and Medicare standards related to Respiratory Therapy

Joint Commission - Same as requirements for Rehabilitation Services Medicare COP - 482.57 Condition of participation:Respiratory care services. (b) Standard: Delivery of Services.Services must be delivered in accordance with medical staff directives. (1) Personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures must be designated in writing. (2) If blood gases or other laboratory tests are performed in the respiratory care unit, the unit must meet the applicable requirements for laboratory services specified in § 482.27. (3) Services must be provided only on, and in accordance with, the orders of a doctor of medicine or osteopathy.

Cite Joint Commission and Medicare standards for documentation of Physician's Orders

Joint Commission - Verbal orders of authorized individuals are accepted and transcribed by qualified personnel who are identified by title or category in the medical staff rules and regulations. Each verbal order is dated and is identified by the names of the individuals who gave and received it. The record documents who implemented it. Individuals who receive verbal orders are qualified to do so and are authorized by the medical staff to do so as identified by title or category of personnel. Medicare COP 428.24 Medical Record Services (c)Standard: Content of record (1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. (i) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner, except as noted in paragraph (c)(1)(ii) of this section. (ii) For the 5 year period following January 26, 2007, all orders, including verbal orders, must be dated, timed, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient as specified under § 482.12(c) and authorized to write orders by hospital policy in accordance with State law. (iii) All verbal orders must be authenticated based upon Federal and State law. If there is no State law that designates a specific timeframe for the authentication of verbal orders, verbal orders must be authenticated within 48 hours. Other - Medical staff can define in the Rules and Regulation those categories of verbal orders that pose a potential hazard to patient. These must be signed by practitioner within a specified period of time, usually 24 hours. An example of an order that might pose a potential hazard is an order for the use of restraints or an order for particular classes of drugs such as chemotherapy drugs. Standing orders - These are a standard set of orders for a particular type of patient, such as post-PTCA or patient undergoing a stent procedure. In CPOE systems, these might be templated that the physician can pull up. In either case the standing orders must be customized for the specific patient.  Standing orders must be signed and dated by a physician with modifications made for the particular patient. Admitting orders are one type of order for which standing orders may be used. For example, a specific physician must have a standing orders for the admission of his/her patients.

Explain Joint Commission and Medicare standards related to pathology reports.

Joint Commission - record contains "all diagnostic and therapeutic procedures and test results". Medicare COP - 482.24 Condition of participation: Medical record services. (c) Standard: Content of record. "(2) All records must document the following, as appropriate: (vi) All practitioners' orders, nursing notes, reports of treatment, medication records, radiology, and laboratory reports, and vital signs and other information necessary to monitor the patient's condition."

Cite Joint Commission and Medicare standards for documentation of Progress Notes

Joint Commission - requires "progress notes made by the medical staff and other authorized individuals" Medicare COP - 4482.24 (c)(2) All records must document the following, as appropriate: (iii) Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. (iv) Documentation of complications, hospital acquired infections, and unfavorable reactions to drugs Other - Medical Staff Rules and Regulations may specify the required frequency of progress notes. Some hospitals used interdisciplinary or integrated progress notes in which the notes of all healthcare professionals are integrated chronologically with the physician's progress notes.

Cite Joint Commission and Medicare standards for documentation of consultations.

Joint Commission - requires that the medical record include any "consultation reports". (Note: not all patients receive consultations). Medicare COP - 482.24 (c)(2) All records must document the following, as appropriate: (iii) Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient.

Explain Joint Commission and Medicare standards related to Occupational, Physical, Speech Therapy and Other Rehabilitation Services

Joint Commission - requires the medical record contain: clinical observations any referrals and communications made to external or internal care providers and to community agencies. the patient's response to care progress notes made by the medical staff and other authorized individuals "When warranted by the patient's need, functional status is assessed." "A functional assessment is performed for each patient referred for rehabilitation services." Medicare COP - 482.56 Condition of participation: Rehabilitation services. (b) Standard: Delivery of services. Services must be furnished in accordance with a written plan of treatment. Services must be given in accordance with orders of practitioners who are authorized by the medical staff to order the services, and the orders must be incorporated in the patient's record.

Explain Joint Commission and Medicare standards related to anesthesia documentation

Joint commission "A preanesthesia assessment is performed for each patient before anesthesia induction". "Each patient's physiologic status is monitored during anesthesia". Medicare COP - 482.52 Condition of participation: Anesthesia services. -(b) Standard: Delivery of services. Anesthesia services must be consistent with needs and resources. Policies on anesthesia procedures must include the delineation of preanesthesia and post anesthesia responsibilities. The policies must ensure that the following are provided for each patient: (1) A preanesthesia evaluation by an individual qualified to administer anesthesia under paragraph (a) of this section performed within 48 hours prior to surgery. (2) An intraoperative anesthesia record.

Requirements for Operative Reports as per Joint Commission and Medicare COP

Joint commission and Medicare COP requires to write and authenticate Operative reports IMEDiTELLY after surgery

What are the three main types of Clinical documentation?

Medical, Nursing and Ancillary

List the data elements that must be included in operative reports

Operative reports include pre-operative and post-operative diagnosis, the names of surgeons and assistants, reason for the procedure, procedure(s) performed, a description of the procedure and the surgical findings, anesthesia used, a description of unusual events or complications and the condition of the patient upon completion (and often before and during the procedure).

What ultimately each document in the medical record should contain?

Sufficient information to clearly identify the patient such as: patient name, health record number, date of birth and gender

Who is responsible for reading (interpreting) the films or scans and authenticating the transcribed report?

The radiologist

Laboratory Report Format

The reports are often in a "cumulative" format. Cumulative reports contain all results from the current episode of care. In cumulative reports, every time a new result is added the entire report is re-generated. When a new cumulative report is added to the medical record, any previous cumulative report should be removed. (It is important that these reports that have been removed be disposed of properly). Anyone purging the record of reports needs to be careful to look at the report date to ensure that the latest cumulative report is kept. Often immediately after discharge when all results are in, a final cumulative report is generated. This report is usually marked at "final" or "discharge" report or is printed on a different color paper. All others are then removed from the record. Results are typically grouped according to the type of test such as hematology, microbiology, urinalysis, chemistry, blood bank, serology, etc.

Explain format for Anesthesia reports

There is always a specific anesthesia form which contains an area for graphing of vital signs during the operative procedure. Some hospitals do not use a separate recovery room record and may therefore expand the anesthesia record to include required post-anesthesia documentation such as the patient's assessment upon discharge from the recovery room.

Routine Consent for Diagnosis and Treatment

authorization for routine care- things like physical examination, routine laboratory tests and general medical care authorization for release of information needed to process claim for reimbursement release of liability for any personal items or valuable the patient keeps in hospital. financial agreement - patient responsibility for bill. Format - Sometimes printed on the back of the Admission/Discharge Record (face sheet) or may be a separate form. Responsibility - Usually Admissions/Registration staff obtain the patient's signature at the time of admission. Other - Also Known As (AKA) Conditions of Admission

Respiratory Therapy contains:

documentation of evaluations and treatments performed by respiratory therapists either for treatment of acute or chronic respiratory conditions or the prevention of respiratory conditions. Services may be treatments such as breathing exercises, ventilator support, therapeutic percussion (the pounding on the chest that is frequently done for cystic fibrosis patients) or specialized testing such as pulmonary function tests. Documentation would include the type of treatment or test, frequency, duration, type and dose of any medications used, oxygen concentrations administered, machines used. Documentation should include patient assessments and response to therapy.

Describe the health information management profession and health information management professionals including their education and credentials

improves the quality of healthcare by insuring that the best information is available to make any healthcare decision. Health information management professionals manage healthcare data and information resources. The profession encompasses services in planning, collecting, aggregating, analyzing, and disseminating individual patient and aggregate clinical data. It serves the healthcare industry including: patient care organizations, payers, research and policy agencies, and other healthcare-related industries.

Nutritional(dietitian's )Documentation contain:

information about the patient's nutritional status and nutritional treatment. Dietitian's documentation may include confirmation of diet orders, diet history, nutritional assessment, nutritional consultations with the patients, periodic assessments of nutrient intake and food tolerance, nutritional care discharge plan, diet instructions.

confidentiality

is your right to keep things about you from being disclosed to other people. So you vest confidentiality in a physician and a healthcare system and by doing that expect them to not disclose information about yourself to others, to keep it confidential.

List the data elements that must be included in Laboratory Reports

the report should contain patient identification information,the name of the test, test date, time in and out of laboratory, test result. The report should also indicate the pathologist in charge of the laboratory. Reports usually also contain the normal value range for each test when appropriate. Often results that are out-of-range are marked in some way such as with an asterisk to call attention to the result. When results are performed by a technologist rather than automatic results reporting by a computer and laboratory equipment, the technologist performing the test is indicated (often with the use of initials or code number). Certain special tests may not be performed by the hospital and are sent out to another lab. These results become part of the patient's medical record and must contain the name of the laboratory performing the test.