Health Record Content and Documentation: Chapter 4

What type of health records may contain family and caregiver input?

Behavioral health records

Which group focuses solely on accreditation of rehabilitation programs and services?

CARF

Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?

Care plan

Administrative data

Coded information contained in secondary records, such as billing records, describing patient identification, diagnoses, procedures, and insurance

Conditions for Coverage

Standards applied to facilities that choose to participate in federal government reimbursement programs such as Medicare and Medicaid

Ancillary services

1. Tests and procedures ordered by a physician to provide information for use in patient diagnosis or treatment. 2. Professional healthcare services such as radiology, laboratory, or physical therapy

Documents imaging

1. The practice of electronically scanning written or printed paper documents into an optical or electronic system for later retrieval of the document or parts of the document if parts have been indexed; 2. The process by which paper-based documentation is captured, digitized, stored, and made available for retrieval by the end-user

Emergency Medical Treatment and Active Labor Act (EMTALA)

A 1986 law enacted as part of the Consolidated Omnibus Reconciliation Act largely to combat "patient dumping" - the transferring, discharging, or refusal to treat indigent emergency department patients because of their inability to pay (Public Law 99-272 1986)

Hybrid record

A combination of paper and electronic records; a health record that includes both paper and electronic elements

Ambulatory surgery center/ ambulatory surgical center (ASC)

A distinct entity that operates exclusively to furnish outpatient surgical services to patients who do not require hospitalization, and are typically discharged less than 24 hours following admission.

Authorization

A document that is required under the Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA) for the use and disclosure of protected health information (PHI).

Minimum Data Set (MDS) for Long-Term Care

A federally mandated standard assessment form that Medicare- and Medicaid-certified nursing facilities must use to collect demographic and clinical data on nursing home residents; includes screening, clinical, and functional status elements

Acknowledgements

A form that provides a mechanism for the resident to recognize receipt of important information

Operative report

A formal document that describes the events surrounding a surgical procedure or operation and identifies the principal participants in the surgery

Medical staff

A group of physicians and nonphysicians such as nurse practitioners and physician assistants who have medical staff privileges

Problem list

A list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification.

Problem-oriented health record

A patient record in which clinical problems are defined and documented individually

Physician orders

A physician's written or verbal instructions to the other caregivers involved in a patient's care

Statute

A piece of legislation written and approved by a state or federal legislature and then signed into law by the state's governor or president

Auto-authentication

A procedure that allows dictated reports to be considered automatically signed unless the health information management department s notified of needed revisions within a certain time limit

Accreditation organization

A professional organization that establishes the standards against which healthcare organizations are measured for compliance with the CoPs and CFCs standards and criteria

Transfer record

A review of the patient's acute stay along with current status, discharge and transfer orders, and any additional instructions that accompanies the patient when he or she is transferred to another facility

Standard

A set of principles, codes, beliefs, guidelines and regulations that have been vetted and agreed upon by an individual or a group of individuals who are regarded as an authority on a particular subject matter.

Patient assessment instrument (PAI)

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

Care plan

A summary of the patient's problems from the nurse or other professional's perspective with a detailed plan for interventions.

Discharge summary

A summary of the resident's stay at a healthcare facility that is used along with the postdischarge plan of care to provide continuity of care upon discharge from the facility

Universal chart order

A system in which the health record is maintained in the same format while the patient is in the facility and after discharge

Integrated 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

Source-oriented health record

A system of health record organization in which information is arranged according to the patient care department that provided the care

Recovery room report

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

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

A patient's gender, phone number, address, next of kin, and insurance policy holder information would be considered what kind of data?

Administrative data

General documentation guidelines apply to:

All categories of healthcare records

Patient history questionnaires, problem lists, diagnostic tests results, and immunization records are commonly found in which type of record?

Ambulatory record

Joint Commission

An independent, non-for-profit national organization that develops standards and performance criteria for health care organizations.

Commission on Accreditation of Rehabilitation Facilities (CARF)

An international, independent nonprofit accreditor of health and human services that develops customer-focused standards for areas such as behavioral healthcare, aging services, child and youth services, and medical rehabilitation programs and accredits such programs on the basis of its standards

Deemed status

An official designation indicating that a healthcare facility is in compliance with the Medicare Conditions of Participation

American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)

An organization that provides an accreditation program to ensure the quality and safety of medical and surgical care provided in ambulatory surgery facilities

When defining its legal health record, a healthcare provider organization must do which of the following?

Assess the legal environment

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?

Consultation

Subjective, objective, assessment plan (SOAP)

Documentation method that refers to how each progress note contains documentation relative to subjective observations, objective observations, assessments, and plans

Consultation report

Documentation of the clinical opinion of a physician other than the primary or attending physician

What electronic record technological capabilities would allow paper-based health records to be incorporated into a patient's EHR?

Documentation-imaging technology

Legal health record

Documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information

Which type of health record contains information about the means by which the patient arrived at the healthcare setting and documentation of care provided to stabilize the patient?

Emergency care

The overall goal of documentation standards is to _____________.

Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient.

Written or spoken permission to proceed with care is classified as:

Expressed consent

Auto-authentication is preferred method of authentication.

False

HIM professionals document in the health record.

False

Only physicians document in the health record:

False

Payers and the government are not concerned with how a physician documents in a health record.

False

When an error is made, the erroneous information can be obliterated.

False

What would not be found in a physical exam?

General condition

The ambulatory surgery record contains information most similar to:

Hospital operative records

The paper health record has been scanned and is now available digitally. What is this known as?

Imaging

Resident assessment instrument (RAI)

In skilled nursing facilities, the care plan is based on a format required by federal regulations

Consent to treatment

Legal permission given by a patient or a patient's legal representative to a healthcare provider that allows the provider to administer care and treatment or to perform surgery or other medical procedures

A patient's registration forms, personal property list, RAI, care plan, and discharge or transfer documentation would be found most frequently in:

Long-term care

Which of the following is the health record component that addresses the patient's current complaints and symptoms and lists the patient's past medical, personal, and family history?

Medical history

Nursing documentation within the health record will be:

Objective

Standing orders

Orders the medical staff or an individual physician has established as routine care for a specific diagnosis or procedure

Which reports provides information on tissue removed during a procedure?

Pathology report

A growth and development record may be found in what type of record?

Pediatric

Informed consent

Permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits

Medical history

Portion of clinical data that addresses the patient's current complaints and symptoms and lists his or her past medical, personal, and family history

The problem list is which part:

Problem-oriented health record

The subjective, objective, assessment, plan (SOAP) method came from the:

Problem-oriented health record

Medical staff privileges

Specific services and procedures that the medical staff member is deemed qualified to perform

A hospital that participates in the Medicare and Medicaid programs must follow

The Conditions of Participation.

Centers for Medicare and Medicaid Services (CMS)

The Department of Health and Human Services agency responsible for Medicare and parts of Medicaid.

Conditions of Participation

The administrative and operational guidelines and regulations under which facilities are allowed to take part in the Medicare and Medicaid programs; published by the Centers for Medicare and Medicaid Services, a federal agency under the Department of Health and Human Services

Progress notes

The documentation of a patient's care, treatment, and therapeutic response, which is entered into the health record by each of the clinical professionals involved in a patient's care, including nurses, physicians, therapists, and social workers

Clinical data

The information that reflects the treatment and services provided to the patient as well as how the patient responded to such treatment and services

Licensure

The legal authority or formal permission from the authorities to carry on certain activities that require such permission (applicable to institutions as well as individuals)

Clinical observations

The observations of physicians, nurses, and other caregivers in order to create a chronological report of the patient's condition and response to treatment during his or her hospital stay

Care area assessments (CAAs)

The patient is assessed and reassessed at defined intervals as well as whenever there is a significant change in his or her condition

History and physical (H&P)

The pertinent information about the patient, including chief complaint, past and present illnesses, family history, social history, and review of body systems

Physical examination

The physician's assessment of the patient's current health status after evaluating the patient's physical condition

Certification

The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements

Authentication

The process of identifying the source of health record entries by attaching a handwritten signature, the author's initials, or an electronic signature

Documentation

The recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregives

Anesthesia report

The report that notes any preoperative medication and response to it, the anesthesia administered with dose and method of administration, the duration of administration, the patient's vital signs while under anesthesia, and any additional products given the patient during a procedure

Expressed consent

The spoken or written permission granted by a patient to a healthcare provider that allows the provider to perform medical or surgical services

Medical staff bylaws

The standards governing the practice of medical staff members typically voted upon by the organized medical staff and the medical staff executive committee and approved by the facility's board of directors

Implied consent

The type of permission that is inferred when a patient voluntarily submits to treatment

Ambulatory

Treatment provided on an outpatient basis

CMS requires that healthcare providers inform their patients about general patient rights afforded to them.

True

Health record entries should be documented at the time of the service they describe are rendered.

True

Healthcare provider organizations normally have patients sign an acknowledgement acknowleding that the healthcare provider organization is not responsible for the loss of or damage to the patient's valuables.

True

Management of health record information is a fundamental component of information governance.

True

Many services such as surgery, infusions, and other diagnostic procedures that once required an overnight hospital stay for the patient, no longer requires that level of care.

True

Only individuals authorized by the organization's policies should be allowed to enter documentation in the health record.

True

Documentation standards

Within the context of healthcare, describe those principles, codes, beliefs, guidelines, and regulations that guide health record documentation

Autopsy report

Written documentation of the findings from a postmortem pathological examination