Chapter 4 - Health Record Content & Documentation
data collected by MDS 3.0 is used for 3 assessments:
- 5 day assessment (mandatory) - interim payment assessment (optional) - discharge assessment (mandatory)
Assessments performed on all Medicare SNF patients:
- 5-day assessment - discharge assessments
documentation standards = appropriate healthcare reimbursement through
- accurate code capture during revenue cycle - reducing inaccurate/fraudulent claims processed & sent to commercial/gov. payers for reimbursement
documentation is important to HIM for:
- coding - claim generation - data quality monitoring - disclosure of health info
quality care & patient safety are acieved through:
- complete - accurate - available healthcare data
For EHR to be legal health record, concepts considered include
- creation & signing of documentation by providers - management & preservation of documentation - impact of documentation on revenue cycle (billing/claims) - display of info for user & on hard copy
When health record lacks accuracy, reliability, & effecitiveness, it fails to
- describe care & treatment of patient - impacts quality of care - assessments & evals - impacts communication - med errors - improper codes - impacts billing & claims submission - jeopardizes accreditation & compliance with state & federal reg.
the overall quality of care & treatment provided to patients is governed by
- granting medical staff privileges - enforcing medical staff bylaws
shortcomings to the paper-based health record
- inability to share needed health information with multiple providers at one time (access & availability) - lack of controls placed in around paper-health records in terms of security
Documentation is now more focused on
- patient care quality - appropriate reimbursement - prevention of fraud & abuse
nurses are responsible for
- specific patient admission & discharge notes - documenting patient's condition at regular intervals - documenting circumstances leading to deaths
application of documentation standards varies based on
- type of health record (inpatient, ambulatory, etc.) - where standards originated (insurance companies/payers, gov. regulatory agencies, licensing boards, accrediting bodies, facility policies & procedures, medical staff bylaws)
CMS mandates the medical staff bylaws must:
1. be approved by governing body of medical staff 2. address duties & privileges of each type of medical staff member 3. describe organization of medical staff 4. describe qualifications required by individuals seeking appointment to medical staff
Health records contain two distinct types of information:
1. clinical 2. administrative
Focal points of the healthcare industry's clinical & operational practices
1. compliance 2. quality 3. patient safety - joint commission has unannounced reviews due to shift in focus
All orders must be:
1. legible 2. dated 3. signed
Medical staff bylaws are required by
1. licensure organizations 2. accreditation organizations 3. federal & state regulatory agencies
EHR has been around for
50 years
established in the late 1970s to survey & accredit various ambulatory-based healthcare providers - surgery centers - imaging centers - endoscopy centers - women's health centers - surveyor is usually expert in place they are surveying - Focused on establishing, reviewing & revising standards, measuring performance, providing education - facility infrastructure, safety, business operations, clinical operations, patient documentation for compliance
Accreditation Association for Ambulatory Healthcare (AAAHC)
• Record that is similar to inpatient surgical health record • Follow-up post-surgery
Ambulatory Surgery Record
Accreditation Association for Ambulatory Healthcare (AAAHC) - accredited
Ambulatory surgery centers
American Osteopathic Association/Healthcare Facilities Accreditation Program (HFAP) - accredited
Ambulatory surgery centers, critical access hospitals, hospital
what is a key component of the Patient Driven Payment Model (PDPM) used by Medicare for Skilled Nursing Facility Reimbursement?
Assessment
The main ways that state & federal government measures a healthcare provider's compliance with the CoP & CfC standards & criteria
Auditing & monitoring
Identifying the source of health record entries - Written signature - Initials - Electronic signature •CMS requires controls to prevent any changes from being made to the health record after the entries have been authenticated
Authentication
procedure allowing dictated reports to be considered automatically signed unless the HIM department is notified of needed revisions within a certain time limit or a process by which the failure of an author to review & affirmatively approve or disapprove an entry within a specified time period results in authentication - When a physician or other care provider authenticates an entry without reviewing - does not meet standards, should not be used
Auto-authentication
who requires a rehab facility to maintain a single case record for any patient it admits?
CARF
Rehab Facilities are accredited through
CARF Joint Commission AOA
ensure patient quality, safety, & improvement of clinical outcomes
CMS Conditions of Participation (CoPs) & Conditions for Coverage (CfCs)
Entries must be •Legible •Complete •Dated and timed •Author identified •Authenticated in written or electronic form
CMS documentation requirements
the federal agency within the Department of Health & Human Services (HHS) known for its operational oversight of the Medicare & Medicaid programs
Centers for Medicare & Medicaid Services (CMS)
information reflecting the treatment & services provided to the patient & patient's response to treatment & services - Largest portion of health record - basis for reimbursement of treatment & services rendered to patient Consists of 9 parts: 1. medical history 2. physical exam 3. diagnostic & therapeutic procedure orders 4. clinical observations 5. diagnostic & procedure reports 6. surgical procedure documentation 7. consultation report 8. discharge summary 9. patient instructions & transfer record
Clinical data
Independent, nonprofit accrediting organization established in 1960s to meet survey needs of various rehabilitation-based healthcare providers - independent/nonprofit providers - aging services - behavioral health - opioid treatment programs
Commission on Accreditation of Rehabilitation Facilities (CARF)
standards applied to healthcare organizations that choose to participate in federal gov. reimbursement programs (Medicare, Medicaid)
Conditions for Coverage (CfCs)
DNV GL Healthcare - accredited
Critical access hospitals, hospital
HIM roles have changed drastically over the past 10-15 years because of the
EHR (more technical focused)
True or false: Auto-authentication is the preferred method of authentication
False
True or false: When an error is made, the erroneous information can be obliterated
False
True or false: Other provider's healthcare records are still put into the legal health record & released as part of the healthcare organization's legal health record
False - a legal council is consulted to determine whether to include the other provider's records in the legal health record - state laws - hospital attorney
physician documentation begins with the
H&P
Who completes these activities? - scanning paper-based health record documentation into the EHR - organizing the content in the health record - analyzing the documentation for deficiencies like physician signatures - coding health record documentation for reimbursement - controlling access & disclosure of health record & content across a healthcare organization
HIM professionals
who is in charge of making sure physician documentation is complete & accurate & health record documentation is organized & readily available when needed for patient care
HIM professionals
Initially created to evaluate osteopathic hospitals (different philosophical & clinical approaches for caring for patient compared to conventional or allopathic approach to medicine), but NOW evaluates ALL healthcare providers - requirements mainly based on CoPs - most surveyors are healthcare professionals themselves (acute care facilities, critical access facilities, hospitals, ambulatory surgery, clinical labs, behavioral health facilities, office-based surgery)
Healthcare Facilities Accreditation Program (HFAP)
Accreditation Commission for Health Care (ACHC) - accredited
Home health, hospice
Community Health Accreditation Program (CHAP) - accredited
Home health, hospice
Center for Improvement in Healthcare Quality (CIHQ) - accredited
Hospital
Clinical observation •Progress note •Integrated health record •Summary statement (death) Care plan
Inpatient record: Clinical
Medical history •Current condition •Past medical history •Personal history •Family history •Chief complaint
Inpatient record: Clinical
Physical exam •Physician assessment Diagnostic and therapeutic procedure order •Physician order •Standing order
Inpatient record: Clinical
•Anesthesia report •Operative report •Recovery room report •Pathology report •Consultation report
Inpatient record: Clinical
•Autopsy report •Vital signs •Flow charts •Diagnostic and therapeutic procedure reports Lab, pathology, and radiology and other tests/treatments
Inpatient record: Clinical
•Discharge summary Overview of encounter Not required for hospitalization less than 48 hours, uncomplicated delivery or newborn •Patient instructions Transfer records
Inpatient record: Clinical
assessment performed when there is a significant change in the patient's situation
Interim payment assessment
a common accreditation organization for hospitals & other healthcare organizations - role in medical staff makeup & content of medical staff bylaws by establishing standards for medical staff bylaws
Joint Commission
•Accredits wide variety of healthcare organizations •Continuously updates survey processes •Surveys clinical and operational components •Provides education to healthcare organizations related to compliance
Joint Commission
•Provides accreditation for: •Ambulatory healthcare •Behavioral health •Critical access hospital •Homecare •Hospital •Laboratory •Nursing care centers •Physician offices •Office-based surgery centers
Joint Commission
- financially rewards healthcare providers for treatment - meeting standards = high quality treatment, efficient, good value - patient outcomes over time = greater emphasis - signed into law in 2015 by Obama
Medicare Access & CHIP Reauthorization Act (MACRA)
two federal & state initiatives related to quality & content of health record documentation - emphasize the quality & efficiency aspects of treatment physicians & other providers to provide patients more than the quantity of the treatment provided
Medicare Access & CHIP Reauthorization Act (MACRA) core measures
CMS dictates that medical bylaws must address certain documentation requirements in the
Medicare Conditions of Participation (CoP)
the standards that a healthcare organization must meet to receive Medicare funding
Medicare Conditions of Participation (CoP)
is used to group patients together into a payment category Includes: - Diagnosis - therapeutic services (PT) - data about patient's level of functioning, etc. - documentation is important for reimbursement & info
Minimum Data Set Version 3 (MDS 3.0)
•Obstetric - Prenatal - Labor and delivery •Newborn - APGAR
Obstetric and Newborn Health Record
is completed on Medicare patients shortly after admission & upon discharge. Based on the patient's condition, services, diagnosis, & medical condition, a payment level is determined for the inpatient rehabilitation stay
PAI (patient assessment instrument)
completed on Medicare patients shortly after admission & upon discharge - patient condition, services, diagnosis, & medical condition determine payment level for inpatient rehabilitation stay - outpatient facilities have separate guidelines
Patient Driven Payment Model
The Compliance Team - accredited
Rural Health Clinics
piece of legislation written & approved by state or federal legislature & signed into law by the state's governor or President of the United States
Statute
True or False The Joint Commission emphasizes appropriate & standardized health record documentation addresses: - health record content - legibility & completeness - dating & timing of entries - order sets - abbreviations - H&P - informed consent
True
True or false: Health record entries should be documented at the time of the services they describe are rendered
True
True or false: Only individuals authorized by the healthcare organization's policies should be allowed to enter documentation in the health record.
True
True or false: physicians may communicate orders verbally or via telephone when the hospital's medical staff rules allow
True - state/medical staff rules specify who can accept & execute orders - signatures & time periods for orders regulated
Home care records typically include: a. An individualized treatment plan b. Operative report c. Pathology report d. APGAR scores
a. An individualized treatment plan
The Joint Commission places emphasis on ________________. a. Appropriate and standardized health record documentation b. Electronic health record technologies used to support documentation c. Clinical and operational practices related to the health record d. Statutes at both the federal and state level
a. Appropriate and standardized health record documentation
A healthcare provider organization, when defining its legal health record must ___________. a. Assess the legal environment, system limitations, and HIE agreements b. Determine what other healthcare provider organizations are doing c. Determine if a legal health record is needed d. Only include the paper components of the health record
a. Assess the legal environment, system limitations, and HIE agreements
The health record being review documents the information from the family. The type of health record being reviewed is: a. Behavioral health records b. Ambulatory surgery health records c. Emergency department health records d. Obstetric health record
a. Behavioral health records
Identify the part of a 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. a. Chief complaint b. Social and personal history c. Past medical history d. Present illness
a. Chief complaint
The fact that ABC hospital is accredited by an accreditation organization that allows the hospital to also meet the Medicare Conditions of Participation is known as: a. Deemed status b. Certification c. Bylaws d. State statute
a. Deemed status
Written or spoken permission to proceed with care is classified as ___________. a. Expressed consent b. Acknowledgment c. Advance directive d. Implied consent
a. Expressed consent
The management of health information is a fundamental component of _____. a. The overall information governance model b. The EHR workflows c. The documentation standards d. Cloud Computing
a. The overall information governance model
An attending physician requests the advice of a second physician who then reviews the health record and examines the patient. The second physician records impressions in what type of report? a. consultation b. progress note c. operative report d. discharge summary
a. consultation
any practice not consistent with goals of providing patients with services that are medically necessary, meet professionally recognized standards, & are priced fairly practices either directly or indirectly resulting in unnecessary costs to Medicare program
abuse
- voluntary process - Periodical evaluation against preestablished written criteria - Healthcare organizations measure their own compliance with standards - Enhances the reputation of the organization in the eyes of the patient - Differs by the type of program or service
accreditation
gives the healthcare organization an opportunity to measure its own compliance & see what operational improvements can be made based on the findings of accreditation organizations - important for patients to know & instills trust with care - enhances reputation among healthcare organizations - voluntary process, but must be done to participate in specific programs & services
accreditation
provided by the Joint Commission that is comprised of chapters addressing various areas of clinical & operational practice - helps organizations obtain/maintain accreditation Includes - Environment of care - Leadership - Provision of Care, Treatment, and Services - Information Management - explanations & scoring for categories
accreditation manual
- Must go through its own CMS review to obtain deemed status - Evaluates healthcare organizations for compliance with CoPs and CFCs
accreditation organizations
measure the compliance of healthcare organizations with standards developed by the accreditation organization
accreditation organizations
keys to meeting compliance standards for documentation
accuracy & appropriateness
a document that the patient or the patient's representative sign, confirming the receipt of important information
acknowledgement
coded information contained in secondary records (such as billing records) describing patient identification & insurance - Includes Patient registration information Patient account information
administrative data
orders that should be found for every patient unless they leave against medical advice
admission & discharge orders
documentation on paper health records occured:
after seeing patient
work more independently than others when providing treatment & services to patient - follow treatment plans, document treatment & response to treatment Two categories: - technician (assistant) & therapist - technologist (must be certified & licensed)
allied health professionals
because of increases healthcare costs, the government has shifted its attention onto
alternative reimbursement payment models
record containing •Demographics •Problem list
ambulatory health record - general
Ambulatory (outpatient) facilities that perform surgery are called: H&P required - operative reports, diagnostic/therapeutic documentation, consultations, discharge notes - follow up calls 24-48 hours postdischarge - assess pain & needs of patient
ambulatory surgery centers (ASC)
American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) - accredited
ambulatory surgery centers, occupational therapy, rural health clinics
responsible for ensuring the presence of key documents as defined by the organization & that health record entries are authenticated & dated
analyst
departments providing treatment & services supporting the patient's overall care plan - play an indirect patient care role, but are necessary for patient care (pharmacy, HIM, nutrition, social services, patient advocacy, patient relations)
ancillary departments
tests & procedures sometimes ordered by a physician - and these services assist the physician with diagnosing & treating the patient - performed by ancillary departments
ancillary services
report noting preoperative medication & response to it, dosage of anesthesia administered & route of administration, duration of administration, vitals under anesthesia, blood products given to patient during procedure - anesthesiologist or nurse anesthetist is responsible for this
anesthesia report
heath records are based on ____ and ____ of the patient's needs in a long-term care facility since their stay at the facility can be lengthy
assessments & reassessments
in the case of a death, who should add a summary statement to the patient's health record to document the circumstances surrounding the patient's death? - can be final progress note or separate report - reason for admission, diagnosis & course in hospital, description of events leading to death
attending physician
permission to disclose information about a patient
authorization
may be requested or required in certain situations when the patient has died - conducted when there is some question about the cause of death or when info is needed for educational or legal purposes - Purpose: Determines or confirms the cause of death or provides more information about the course of a patient's disease
autopsy (necropsy)
a description of the examination of a patient's body after she/he has died - completed by pathologist & becomes part of patient's health record - format standardized by National Association of Medical Examiners Contains: - diagnosis - toxicology - opinion - circumstances of death - identification of decendent - general description of clothing & personal effects - evidence of medical intervention - external examination - external evidence of injury - internal examination - samples obtained - preliminary report developed since results take months - authorization from next of kin or by law enforcement
autopsy report
The patient's medical history can be completed within _____ of admission to the hospital a. 3 days b. 30 days c. 60 days d. 10 days
b. 30 days
Critique each statement to determine the true statement about behavioral health records. a. Behavioral health records are completely different from other health records. b. Behavioral health records are similar to other health records. c. Behavioral health records do not record the input of family members. d. Behavioral health records do not record the input of social workers.
b. Behavioral health records are similar to other health records.
What standard must a hospital that participates in the Medicare and Medicaid programs comply with that hospitals who do not accept Medicare and Medicaid patients do not? a. Medical bylaws of the healthcare provider organization b. Conditions of Participation c. Accreditation organization d. Documentation standard
b. Conditions of Participation
Identify the documentation that tells the nurses and others what to do. a. Progress notes b. Diagnostic and therapeutic orders c. Discharge summary d. Consultation report
b. Diagnostic and therapeutic orders
a summary of the patient's health record is found in the a. Progress notes b. Discharge summary c. Care plan d. Physical examination
b. Discharge summary
the healthcare organization needs to incorporate paper-based health records into the patient's EHR. It should use: a. Database management b. Document imaging c. Text processing d. Vocabulary standards
b. Document imaging
An electronic record technological tool that allows a paper-based x-ray report to be accessed is _____. a. Database management b. Documents imaging c. Text processing d. Vocabulary standards
b. Documents imaging
The Medicare Access and CHIP Reauthorization Act (MACRA) is a(n)________. a. New privacy law b. Federal healthcare quality improvement initiative c. New federal insurance program d. Accrediting organization
b. Federal healthcare quality improvement initiative
When a patient goes into labor & subsequently delivers a newborn, what documentation will be found in the Labor & Delivery record? a. Apgar scores b. Fetal monitoring strips c. Obstetrical risks d. Medical history
b. Fetal monitoring strips L&D documentation includes 1. fetal monitoring strips 2. medications given & stopped 3. nursing progress notes
Documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information is defined as the: a. Business record b. Legal health record c. Liability record d. Shadow health record
b. Legal health record
Nursing documentation within the health record is: a. Subjective b. Objective c. Both subjective & objective d. Electronic
b. Objective
Which of the following is an example of clinical data? a. Patient consent b. Physician orders c. Patient registration d. Name of insurance company
b. Physician orders
The Subjective, Objective, Assessment Plan (SOAP) came from the _____. a. Source-oriented health record b. Problem-oriented health record c. Hybrid health record d. Depends on facility policy
b. Problem-oriented health record
A chronological report of the patient's condition and response to treatment during a hospital stay is known as _____. a. Physical examination b. Progress notes c. Physician order d. Medical history
b. Progress notes
Each entry in the health record should be: a. Signed only b. Signed and dated c. Reviewed by the patient d. Reviewed by another physician
b. Signed and dated
The S in SOAP is: a. Superior b. Subjective c. Simple d. Sample
b. Subjective
A new hospital in town wants to accept Medicare patients. To receive Medicare funding, the hospital must meet: a. The medical bylaws of the healthcare provider organization b. The Medicare Conditions of Participation c. The accreditation organization d. The plan
b. The Medicare Conditions of Participation
Critique each statement to determine the true statement related to correcting errors in the paper-based health record entries. a. Addendum should be backdated b. The reason for the change should be noted c. The incorrect information should be obliterated d. The phrase late entry should be noted on the entry
b. The reason for the change should be noted
health record including - treatment plan with family/caregiver input - assessments geared toward transition to outpatient, nonacute treatment CMS requires social workers assigned to patient to document family/home environment & community services unique to patient - psychiatric evaluation by healthcare provider - patient history, current mental status, cognitive function
behavioral health
Most SNFs, NFs, and ICF-MRs long-term care facilities are governed by:
both federal & state regulations, including Medicare CoP
A patient's gender, phone number, address, next of kin, & insurance policyholder information would be considered what kind of data? a. Clinical data b. Authorization data c. Administrative data d. Consent data
c. Administrative data
The type of health record that records a nurse calling a patient 24 to 48 hours after they leave the healthcare setting a. Behavioral health b. Ancillary services c. Ambulatory surgery center d. Long term care facility
c. Ambulatory surgery center
The health record format that is most commonly used by healthcare settings as they transition to electronic records is a. Integrated records b. Problem-oriented records c. Hybrid records d. Paper records
c. Hybrid records
Complete and accurate health record information _________________. a. Increases healthcare costs b. Decreases coding accuracy c. Increases quality of treatment d. Has no impact on cost, coding accuracy, or quality of treatment
c. Increases quality of treatment
The federal Conditions of Participation apply to a. Organizations that are accredited b. Organizations that provide acute care services c. Organizations that treat Medicare or Medicaid patients d. Organizations that are subject to the Health Insurance Portability and Accountability Act
c. Organizations that treat Medicare or Medicaid patients
Documentation standards have become more detailed and have become focused on ________. a. EHR technology b. Licensure requirements c. Patient care quality d. Accreditation standards
c. Patient care quality
As the government has shifted its focus towards quality, alternative reimbursement and payment models have developed. An example is: a. Bundled payments b. Managed care c. Pay-for-performance d. Fee-for-service
c. Pay-for-performance
Justify the need for the discharge summary. a. Providing information about the patient's insurance coverage b. Ensuring the other healthcare providers know what to do next while the patient is hospitalized c. Providing information to support the activities of the medical staff review committee d. Documenting the patient's health history in detail
c. Providing information to support the activities of the medical staff review committee
Recommend a method of facilitating documentation of orders for routine procedures and other common situations a. Physician's office records b. Emergency care records c. Standing order d. Order sets
c. Standing order
a summary of the patient's problems from the nurse or other professional's perspective with a detailed plan for interventions - may follow the assessment - used by nurses to perform assessments focused on understanding the patient's condition from the perspective of their specialized body of knowledge
care plan
type of health record frequently used by hospitals - inpatient & outpatient health record documentation is maintained in one health record rather than in separate health records
centralized health record
process by which a duly authorized body evaluates & recognizes an individual, institution, or educational program as meeting predetermined requirements - programs commonly getting this are ones that address asthma, diabetes, & heart failure
certification
a component of the medical history that is told to the healthcare provider by the patient and in the patient's own words - nature & duration of the symptoms that caused the patient to seek medical attention as stated in his or her own words
chief complaint
after treatment, patient health record is put into what order?
chronological order
the recovery progress that has begun in the hospital continues when a patient is given
clear & concise instructions upon discharge - verbal & in writing - signature of physician giving instructions & signature of patient understanding - copy of instructions in health record
what plays a key role in demonstrating if a healthcare provider is meeting or exceeding performance measures to receive financial payment
clinical documentation
who works with physicians to ensure the documentation is completed & contains enough information to assign diagnosis & procedure codes? (identifies whether left or right radius was fractured, etc.)
clinical documentation coordinator
the comments of physicians, nurses, & other caregivers creating a chronological report of the patient's condition & response to treatment during his/her hospital stay - provided as a progress note
clinical observations
Documents the clinical opinion of a physician other than the primary or attending physician - usually requested by primary physician - based on physician's review of patient & health record
consultation report
- patient's preoperative & postoperative diagnosis - descriptions of the procedure(s) performed - descriptions of all normal & abnormal findings - description of patient's medical condition before, during, & after surgical procedure - estimated blood loss - descriptions of any specimens removed - descriptions of any unique or unusual events during surgical procedure - names of surgeons & assistants - date & duration of surgical procedure
content of operative report
- Healthcare provider organization's processes for self-governance & general oversight obligations - due process rights as they relate to potential disciplinary action - peer review policies & procedure - medical staff appointment, privileging, & credentialing
content required in medical staff bylaws
national treatment standards for specific healthcare conditions developed, & still developed & updated based on scientific & clinical findings - improve overall patient outcomes during treatment of conditions Goal: reduce patient adverse events & complications - documentation must reflect adherence to core measures - reported by providers monthly or quarterly to CMS, JC, etc. - documentation & adherence demonstrates how frequently healthcare provider follows standards related to specific healthcare conditions - reflects level of quality & care from healthcare provider to patient population
core measures
process of reviewing & validating qualifications (degrees, licenses, etc.) of physicians & other licensed independent practitioners for granting medical staff privileges to provide patient care services
credentialing
The Healthcare Facilities Accreditation Program (HFAP) accredits_________. a. Only osteopathic facilities b. Only allopathic facilities c. Only ambulatory facilities d. All healthcare facilities
d. All healthcare facilities
The healthcare organization has decided to become accredited by an accreditation organization that focuses on rehabilitation programs and services. The healthcare organization should select _______ as their accrediting organization. a. HFAP b. Joint Commission c. AAAHC d. CARF
d. CARF
The overall goal of documentation standards is to ______________. a. Ensure physicians have access to the health record information they need to care for the patient b. Ensure that the healthcare provider organization is reimbursed appropriately by payers c. Ensure that the Centers for Medicare and Medicaid Services (CMS) do not find reason to fine the healthcare provider organization d. Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient
d. Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient
A patient's registration forms, personal property list, MDS and care plan and discharge or transfer documentation would be found most frequently in the ___________ health record. a. Rehabilitative care b. Ambulatory care c. Behavioral health d. Long-term care
d. Long-term care
a patient's registration forms, personal property list, RAI, care plan, & discharge or transfer documentation would be found most frequently in which type of health record? a. Rehabilitative care b. Ambulatory care c. Behavioral health d. Long-term care
d. Long-term care
the assessment used by a rehabilitation center is known as a. Care plan b. OASIS c. MDS d. PAI
d. PAI
Identify the example of administrative information. a. Admitting diagnosis b. Blood pressure records c. Medication records d. Patient's address
d. Patient's address
documentation should be authenticated, accurate, legible, complete, and: a. Based solely on clinical care b. Based solely on reimbursement c. Electronic d. Timely
d. Timely
Justify the need for documentation standards a. To ensure physicians have access to the health record information they need to care for the patient b. To ensure the healthcare provider organization is reimbursed appropriately by payers c. To ensure CMS does not find reason to fine the healthcare provider organization d. To ensure what is documented in the health record is complete & accurately reflects the treatment provided to the patient
d. To ensure what is documented in the health record is complete & accurately reflects the treatment provided to the patient
the physician spoke to a patient about the risks & benefits of a treatment or procedure. this is known as: a. consultation b. clinical evaluation c. implied consent d. informed consent
d. informed consent
Dr. Smith admits patients to the ABC hospital. There he is able to perform general surgery, order tests, and perform other services. This is known as: a. certification b. licensure c. statutes d. medical staff privileges
d. medical staff privileges
The originating department organizes the paper-based health record. This is an example of: a. problem-oriented health record b. SOAP methodology c. universal chart order d. source-oriented health record
d. source-oriented health record
Federal and state documentation initiatives as well as the subsequent reimbursement and payment models are now focusing on ____________. a. the quantity of healthcare services provided b. the efficiency and value of the healthcare services provided c. the quality of the healthcare services provided d. the efficiency, quality, and value of healthcare services provided
d. the efficiency, quality, and value of healthcare services provided
The reliability & effectiveness of data for its intended uses in operations, decision-making, & planning - documentation is appropriate, accurate, reliable, readily accessible used for health record, billing/claims data, administrative/business data, disease registry data
data quality
An official designation indicating that a healthcare facility is in compliance with the Medicare Conditions of Participation after CMS review - allows accreditation organizations to evaluate other healthcare provider organizations for CoP & CfC compliance through an accreditation process - 9 national accreditation organizations have this
deemed status
data that identifies the patient
demographic data
•Physician order •Standing order
diagnostic & therapeutic procedure order
include orders for x-rays, CT, MRI, lab tests, etc. for the purpose of diagnosing a patient's symptoms of illness
diagnostic orders
- Lab tests (blood, urine, body fluids) - pathological examinations of tissue samples & tissues or organs removed during procedures - Imaging procedures of patient's body & specific organs (radiology, scans, ultrasounds, MRIs, PETs) - Monitors & tracings of body functions - lab tests = automatically generated - monitors, imaging, pathology = interpretation by cardiologists, radiologists, pathologists, etc.
diagnostic procedure reports
If a patient's stay is not complicated, lasts less than 48 hours, or involves uncomplicated delivery of a newborn, what is in place of a full discharge summary?
discharge note
A concise account of the patient's illness, course of treatment, response to treatment, and condition at discharge is called a: - summary provides overview of entire medical encounter - responsibility of attending physician that must be signed
discharge summary
includes instructions for follow up care given to patient or caregiver at time of discharge - ensures continuity of future care by providing info to patient's attending physician, referring physician, and consulting physicians - provides info to support activities of the medical staff review committee - provides concise information that can be used to answer information requests from authorized individuals or entities
discharge summary
process by which paper-based documentation is captured, digitalized, stored & made available for retrieval by the end user • Capture, digitize, integrate, store, and retrieve paper-based health record documentation • Organizes and assembles the paper-based health record documentation, and controls the versioning, access, and search capabilities of the documentation
document imaging
Recording of pertinent health record findings, interventions, & responses to treatment - business record - form of communication for caregivers - allows for continuity of care & treatment - permanent health record for all future care of patient - provides complete medical picture of patient - must be complete, accurate, support quality incentives, meet accreditation requirements
documentation
progress notes lab tests radiology imaging reports operative reports - examples of what?
documentation
standard that controls health record documentation
documentation standard
describe those principles, codes, beliefs, guidelines, & regulations that guide health record documentation - dictates how healthcare providers should document treatment & services to patient within health record - Basis of standards: promote healthcare quality & safety & provided for optimized continuity of care for patient
documentation standards
Special notes in a health record include
documenting patient's condition that may affect treatment - pre & post surgery evals
what a legal health record contains is defined by
each healthcare organization
consent to treatment that is either written or verbal
expressed consent
True or false: HIM professionals document in the health record
false
true or false: the level & complexity of care a home care patient needs do not determine the skill level of the individual providing care to the patient
false
true or false: documentation standards of the EHR are completely different than the standards for documentation in a paper-based record
false
diseases among relatives in which heredity or contact might play a role such as allergies, cancer, & infectious, psychiatric, metabolic, endocrine, cardiovascular, & renal diseases; health status or cause of & age at death for immediate relatives
family medical history
nurse records are also called - show trends over time - data represented in graphic form to ease communication
flow records
the intentional deception or misrepresentation that an individual knows, or should know, to be false or does not believe to be true, knowing the deception could result in some unauthorized benefit to himself or other person(s)
fraud
apply to all categories of health records address: - uniformity, accuracy, completeness, legibility, authenticity, timeliness, frequency, format of health record entries •Every healthcare organization should have policies
general documentation guidelines
ensuring what is documented in the health record is complete & accurately reflects treatment provided to patient - = inherent level of acceptable quality for providers to understand patient condition & responses to treatments
goal of documentation standards
centralizes documentation regarding patient's healthcare visit & treatment history in an official, permanent, & recorded format - enables patient's healthcare providers to make well-informed concurrent treatment decisions for patient & establishes patient's healthcare history for future reference
health record
what has been developed by the government to improve the quality of care provided & increasing efficiencies with an increased value of the care provided to patients
healthcare incentives
complete & accurate health record documentation drives what kind of patient care, as well as appropriate coding & claims submission for appropriate reimbursement
high-quality patient care
CMS medical bylaw requires this documentation type for every patient no more than 30 days before or 24 hours after admission to the hospital - contains pertinent info about patient, chief complaint, past/present illnesses, family history, social history, review of body systems - must be documented in health record before surgeries/procedures requiring patient anesthesia - if physical exam is done within 30 days of procedure, updated exam required within 24 hours of admission prior to procedure. - includes changes in condition since first exam
history & physical (H&P)
medical history & physical examination together are called
history & physical (H&P)
record including documentation reflecting care & treatment provided to patients in the home setting - basic assistance & allows patient to be independent in own home - short term rehab or comprehensive management of chronic illness - care is individualized based upon the needs of the patient - accurate & complete documentation = quality & better outcomes - quality documentation = appropriate coding, claims, reimbursement Includes: - individualized treatment plan - general health assessment - problem list - treatment goals - interventions & outcomes - communication with other providers
home health record
legal health record is complicated now since we are in the ___-record model and transitioning fully to the electronic format & info is scattered
hybrid-record model
- Poor outcomes - Issues with patient care - Issues with accuracy of diagnosis/procedure codes - errors on healthcare claim
impact of poor documentation
consent communicated through conduct other than words, such as an unconscious person who is brought to an emergency department
implied consent
EHR allows documentation to take place
in exam room/during treatment - positively impacted workflow
- chief complaint - present illness - past medical history - social & personal history - family medical history - review of systems
included in a complete medical history
- general condition - vital signs - skin - head - eyes - ears - nose & sinuses - mouth - throat - neck - thorax, anterior & posterior - breasts - lungs - heart - abdomen - male genitourinary organs - female reproductive organs - rectum - musculoskeletal system - lymphatics - blood vessels - neurological system - diagnose(s)
included in physical examination
organization-wide framework for managing information throughout its life cycle & supporting the organization's strategy, operations, regulatory, legal, risk, & environmental requirements
information governance
the governance or management of health record information is a fundamental component of the
information governance model
the process by which the healthcare provider informs or makes the patient knowledgeable about the risks & benefits of the proposed treatment or procedure
informed consent
record where: • Patient stays overnight • Medical or surgical • Most complex health record
inpatient health record
type of health record generated when a patient is provided with room, board, & continuous general nursing care in an area of an acute-care healthcare organization such as a hospital, where the patient generally stays overnight at the healthcare organization - H&P - consultation reports - physician's orders - progress notes - nursing assessments & progress notes - discharge summary
inpatient health record
A system of health record organization in which all the paper forms are arranged in strict chronological order and mixed with forms created by different departments
integrated health record
record where documentation is placed in chronological order regardless of its source - lab results, notes, etc. are placed in the order they occurred Order determined by: - when documentation was entered into health record - when service/treatment was rendered - when a test result was processed
integrated health record
used to ensure compliance with laws & regulations, healthcare policies, accreditation standards, etc.
legal health record
legal authority or formal permission from authorities to carry out certain activities requiring such permission ex: hospital must be licensed by state to treat patients
licensure organizations
type of care provided in settings such as skilled nursing facilities, subacute-care facilities, nursing facilities, nursing homes, and assisted living facilities •Ongoing assessments •Care plan Resident Assessment instrument Minimum Data Set for Long-Term Care
long-term care
record containing: - registration forms (identification data) - personal property list - H&P & hospital records - advance directives, bill of rights, other legal records - clinical assessments - RAI & care plan - physician orders - physician progress notes & consults - nursing notes - rehab therapy notes - social services, nutrition, activities - medication, records of monitors, restraints - lab, radiology, special reports - discharge or transfer documentation
long-term care record
type of health record pertaining to adult patients with various acute & active disease processes & Injuries - used in a variety of settings - interdisciplinary documentation - categories: clinical data administrative data consents authorizations acknowledgements
medical and surgical health record
addresses the patient's current complaints & symptoms & describes his/her past medical, personal, & family history - responsibility of attending physician in inpatient care - focuses on body systems involved in current illness
medical history
Physicians and nonphysician providers (NPs, PAs, etc.) who have privileges to practice medicine at a particular healthcare organization - may or may not be employed by the healthcare organization
medical staff
govern the business conduct, rights, & responsibilities of medical staff medical staff must abide by these to practice in the healthcare organization
medical staff bylaws
standards that govern the practice of medical staff members - federal & state regulatory agencies mandate content, specifically the breadth & depth - Vary slightly between organizations because of state laws & individual needs - used to enforce quality of care
medical staff bylaws
a specific list of services & procedures that a medical staff member may perform at a particular healthcare organization after education & ensuring qualifications of member
medical staff privileges
do HIM professionals document in the health record?
no
do most long-term care providers participate in voluntary accreditation programs?
no - Joint Commission does have long-term care facility standards
healthcare providers playing an important role in day-to-day caregiving of a patient, & important member of patient care team - documentation is based on environment - data captured depends on licensing & regulatory requirements & organizational policies & procedures - legible, complete, timely documentation required - documentation is only objective - more restrictive than physician's documentation since they aren't actually diagnosing patients
nurses
report describing in detail the surgical procedures performed on the patient - written or dictated by surgeon immediately after surgery & becomes part of health record as soon as possible - progress note added when dictation is delayed - other procedures such as blood transfusions, chemotherapy, etc. documented
operative report
identifying the legal health record was easy when the health record was primarily ____-based & included contents of ___ record & diagnostic radiographic films/x-rays
paper
The healthcare provider must demonstrate they at least meet, or exceed the CoPs & CfCs in order to:
participate in federal government reimbursement programs
summary of childhood & adult illnesses & conditions, such as infectious diseases, pregnancies, allergies & drug sensitivities, accidents, operations, hospitalizations, & current medications
past medical history
dictated by a pathologist after examination of tissue received for evaluation - description of tissue from the eye & cells at microscopic level
pathology report
when tissue is removed during surgery, what report must be present?
pathology report
includes data elements obtained during the patient registration process - takes place before physician examines or begins treating patient - includes demographic data
patient registration information
- patient's full name - health record number - account number for visit - patient's address - phone number - date of birth - gender - marital status - religious affiliation - race - next of kin info - healthcare power of attorney or advance directives - if patient wants to be a private or confidential patient under HIPAA (opts out of healthcare organizations directory)
patient registration information (demographic data)
authenticated, accurate, legible, complete & timely documentation is paramount to:
patient safety, quality of care provided to patients, appropriate reimbursement
prioritizes quality & efficiency rather than quantity
payment models (pay-for-performance, value-based care) - financial incentives boosting patient outcomes - requirements must be met to receive financial payment
represents the physician's assessment of the patient's current health status after evaluating the patient's physical condition - ensures proper treatment & services for patient
physical examination
role is not as visible in long-term care - develops a plan of treatment including meds & treatments for resident - usually visits on a 30 or 60 day schedule - each visit: review plan of care, reviews orders, makes changes - nursing updates with changes in condition
physician
Record containing: - Medical history - family history - social history - vital signs - chief complaint - progress notes - allergies - medication list - history of present illness - review of systems - assessment & diagnosis - plan of treatment
physician office record
routine healthcare treatment commonly occurs within the: - preventative services - diagnosis & treatment of minor illnesses or injuries
physician office setting
instructions given by the physician to other healthcare professionals who perform diagnostic tests & treatments, administer medications, & provide specific services to a particular patient - ordering a nurse to take temp every 2 hours
physician orders
patients rely on these healthcare professionals to make sound medical decisions about them & document them accordingly - payers & gov. rely on them to document appropriately for quality of care & appropriate reimbursement to payer - information documented impacts patient - documentation is subjective & objective
physicians
detailed chronological description of the development of the patient's illness, from the appearance of the first symptom to the present situation
present illness
defines & documents clinical problems individually Consists of: - problem list - H&P - initial lab findings (database) - initial plan (test, procedures) - progress notes
problem-oriented health record
the SOAP methodology came from the ____ (developed by Lawrence Reed in the 1970s)
problem-oriented health record
serve to justify further acute-care treatment in healthcare organizations - document appropriateness & coordination of services provided - patient's condition = frequency of notes - contains clinical observations
progress note
used for paper records in a long term care setting when records become too thick
record thinning
name for post anesthesia report
recovery room report
report including the post-anesthesia note, nurse' notes regarding patient's condition & surgical site, vital signs, IV fluids, etc.
recovery room report
focus of services are to increase a patient's ability to function independently within the parameters of the individual's illness or disability - reimbursed by Medicare
rehabilitation (physical medicine)
record including - patient identification data - pertinent history (functional history) - diagnosis of disability & functional diagnosis - rehab problems, goals, & prognosis - reports of assessments & program plans - reports from referring sources & service referrals - reports from outside consults & lab, radiology, orthotic, & prosthetic services - designation of manager for patient's 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
rehabilitation health record
order of the health record when a patient is being treated
reverse chronological order
systemic inventory designed to uncover current or past subjective synonyms for body systems
review of systems
what specifies which healthcare providers can enter progress notes in the health record? - includes guidelines for frequency of notations
rules & regulations of hospital's medical staff
marital status; dietary, sleep, and exercise patterns; use of coffee, tobacco, alcohol, & other drugs; occupation; home environment; daily routine
social & personal history
format where the documentation of a paper-health record is organized by source or originating department - all nursing notes together, all physician progress notes together, etc. - documentation in reverse chronological order, so most current/recent documentation is first
source-orientated health record
set of principles, codes, beliefs, guidelines, & regulations that have been vetted & agreed upon by an individual or a group of individuals regarded as an authority on a particular subject matter. - based on generally accepted rules of healthcare industry
standard
orders the medical staff or an individual physician established as routine care for a specific diagnosis or procedure - authorizes healthcare providers to treat patient before physician examines patient - signed, verified, dated
standing orders
vary by state in terms of what components of health record documentation are regulated & to what degree it is regulated by law - addresses documentation requirements according to health record type
state statutes
method used to construct physician progress notes. - used to remember what elements of documentation must be included in the progress note
subjective, objective, assessment, plan (SOAP)
documentation requiring preop notes from anesthesiologist & surgeon, nurse's preop preparations, entire procedure, anesthesia record, operative report, post-anesthesia/recovery room report
surgical procedure documentation
a pattern used in the EHR to capture data in a structured manner & specify information to be collected - helps with key information - data captured in specific order & format
template
Leveraging EHR features & technical capabilities in conjunction with strong & concise policies & procedures can ensure:
the integrity & accuracy of health record documenation
orders for treatment that either prevent or address illness by way of medication administration, surgery, or counseling
therapeutic orders
record used when a patient is being transferred from the acute setting to another healthcare organization - Includes Brief review of patient's acute stay patient's current status discharge/transfer orders - social services & nurses complete their portions
transfer record
True or false Healthcare providers accredited by an approved accreditation organization are exempt from direct government auditing & monitoring
true
True or false: Each healthcare organization will define appropriate content & frequency of documentation based on specific regulations & standards & profession's practice guidelines
true
True or false: HIM professionals are experts in the development of workflows related to the EHR
true
True or false: HIM professionals use the health record for coding
true
True or false: Many services such as surgery, infusions & other diagnostic procedures that once required an overnight hospital stay for the patient no longer require that level of care
true
True or false: Results of all diagnostic & therapeutic procedures become part of the patient's health record
true
True or false: pay-for-performance initiatives focus on treatment quality, efficiency, & value rather than the quantity of treatment provided
true
true or false: HIM professionals are viewed as the experts to develop workflows & infrastructure around the EHR
true
where the health record post patient discharge is kept in reverse chronological order
universal chart order
nurses maintain chronological records of
vital signs inputs
how are medical staff bylaws put into place?
voted upon by organized medical staff & medical staff executive committee & approved by healthcare organization's board of directors - important in documentation standard mandates & development
general documentation guidelines
• All entries in the health record should be permanent. - For errors, draw line through info & write error on top. Add signature, date, time, reason for change, title & discipline of individual making correction • Any corrections or information added to the record by the patient should be inserted as an addendum - No changes should be made in the original entries in the record - Information added to the health record by the patient should be clearly identified as an addendum
Documentation by setting
• Must have health record for each person • Content varies by setting • Contains clinical and administrative data
general documentation guidelines
•Authors of entries should be clearly identified in the record. •Only abbreviations and symbols approved by the organization or medical staff rules and regulations should be used in the health record.
general documentation guidelines
•Organized systematically to facilitate data retrieval and compilation •Only individuals authorized by the organization's policies should be allowed to enter documentation in the health record. •Organizational policy or medical staff rules and regulations should specify who may receive and transcribe verbal physician's orders. •Health record entries should be documented at the time the services they describe are rendered.
