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Health Information Management Technology: An Applied Approach, Sixth Edition

Chapter 4: Health Record Content and Documentation

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Documentation

Recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregivers

Allows for the telling and retelling of events

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Impact of Poor Documentation

Poor outcomes

Issues with patient care

Issues with the accuracy of diagnosis and procedure codes

Errors on healthcare claim

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Describes those principles, codes, beliefs, guidelines, and regulations that guide healthcare documentation.

Dictates how healthcare providers should document the treatment and services within the health record.

Documentation Standards

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Standard

Set of principles, codes, beliefs, guidelines, and regulations that have been vetted and agreed upon by an individual or a group of individuals.

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Documentation Standard

Standard that controls health record documentation

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EHRs and paper-based health records typically have the same basic documentation standards

Templates

Documentation Standards and EHRs

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Standards

Documentation standards have grown in complexity and detail over time

Focus on

Patient care quality

Appropriate reimbursement

Prevention of fraud and abuse

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Standards

Documentation standards vary upon the type of health record

Multiple sources of documentation standards:

Insurance company or payers

Government regulatory agencies

Licensing boards

Accrediting bodies

Facility policies and procedures

Medical staff bylaws

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Goals of Documentation Standards

Ensure complete health record and accurately reflects the treatment provided to the patient

Drive appropriate reimbursement through accurate code capture

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Medical Staff Bylaws

Standards governing the practice of medical staff members

Voted on by the organized medical staff and the medical staff executive committee

Approved by the healthcare organization’s board of directors

Used to enforce quality of care

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Required by

Licensure organizations

Accreditation organization

Federal and state regulatory agencies

Each organization mandates content

Medical staff bylaws will vary slightly from one organization to another

Medical Staff Bylaws

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Medical Staff

Physicians and nonphysician providers who have privileges to practice medicine at a particular healthcare organization

May or may not be employed by the healthcare organization

Medical staff are subject to the medical staff bylaws

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Medical Staff Privileges

Specific services and procedures that the medical staff member is deemed qualified to perform, at a particular healthcare provider organization

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Accreditation

A 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

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Accreditation

Healthcare organizations that are accredited by an approved accreditation organization are exempt from routine state survey agencies

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Accreditation Organization

Must go through its own CMS review to obtain deemed status

Evaluates healthcare organizations for compliance with CoPs and CFCs

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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

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Joint Commission

Provides accreditation for:

Ambulatory healthcare

Behavioral health

Critical access hospital

Homecare

Hospital

Laboratory

Nursing care centers

Physician offices

Office-based surgery centers

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Other Accreditation Organizations

Healthcare Facilities Accreditation Program

Commission on Accreditation of Rehabilitation Facilities

Accreditation Association for Ambulatory Healthcare

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State Statutes

Legislation written and approved by a state legislature and then signed into law by the state’s governor

Addresses the documentation requirements for specific types of health records

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Legal Health Record

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

Content varies from provider organization to another

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Legal Health Record

Policies and procedures should be established to defining legal health record

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General Documentation Guidelines

Apply to all categories of health records

Every healthcare organization should have policies

Organized systematically to facilitate data retrieval and compilation

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General Documentation Guidelines

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.

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General Documentation Guidelines

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

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.

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General Documentation Guidelines

All entries in the health record should be permanent.

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

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CMS Documentation Requirements

Entries must be

Legible

Complete

Dated and timed

Author identified

Authenticated in written or electronic form

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Authentication

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

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Auto-Authentication

When a physician or other care provider authenticates an entry without reviewing

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Documentation by Setting

Health record information consists of two types regardless of setting

Clinical

Administrative

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Documentation by Setting

Must have health record for each person

Content varies by setting

Contains clinical and administrative data

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Inpatient Health Record

Patient stays overnight

Medical or surgical

Most complex health record

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Inpatient Health Record—Clinical

Medical history

Current condition

Past medical history

Personal history

Family history

Chief complaint

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Inpatient Health Record—Clinical

Physical exam

Physician assessment

Diagnostic and therapeutic procedure order

Physician order

Standing order

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Inpatient Health Record—Clinical

Clinical observation

Progress note

Integrated health record

Summary statement (death)

Care plan

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Inpatient Health Record—Clinical

Autopsy report

Vital signs

Flow charts

Diagnostic and therapeutic procedure reports

Lab, pathology, and radiology and other tests/treatments

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Inpatient Health Record—Clinical

Anesthesia report

Operative report

Recover room report

Pathology report

Consultation report

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Inpatient Health Record—Clinical

Discharge summary

Overview of encounter

Not required for hospitalization less than 48 hours, uncomplicated delivery or newborn

Patient instructions

Transfer records

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Inpatient Health Record—Administrative

Patient registration

Demographics

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Special Health Records

Some health records have unique requirements because of the specialized services provided

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Obstetric and Newborn Health Record

Obstetric

Prenatal

Labor and delivery

Newborn

APGAR

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Ambulatory Health Record - General

Demographics

Problem list

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Ambulatory Surgery Record

Similar to inpatient surgical health record

Follow-up post surgery

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Ancillary Departments

Tests and procedures

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Physician Office Record

Preventive care

Minor illnesses and injuries

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Long-Term Care

Ongoing assessments

Care plan

Resident Assessment instrument

Minimum Data Set for Long-Term Care

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Rehabilitation

Minimum Data Set, Version 3 (MDS 3.0) Resident Assessment Instrument

5-Day Assessment (mandatory)

Interim Payment Assessment (optional)

Discharge Assessment (mandatory)

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Behavioral Health

Includes similar content

Family and caregiver input is documented

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Home Health

Treatment plan

Health assessment

Problem list

Treatment goals

Interventions and outcomes

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Federal and State Initiatives on Documentation

Trends are to focus on

Quality of care provided

Value-based care

Reimbursement provide incentives for quality of care

MACRA

Core Measures

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Paper Health Record—Format

Source-oriented health record

Universal chart order

Integrated health record

Problem-orientated medical record

Subjective, Objective, Assessment, Plan (SOAP)

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Electronic Health Record

Point-of-care documentation

Documentation captured electronically

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Web-Based Document Imaging

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

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Role of Healthcare Professionals in Documentation

Physicians

Document appropriately so that quality care can be rendered and that appropriate reimbursement can occur

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Role of Healthcare Professionals in Documentation

Nurses

Documentation varies by licensing and regulatory requirements, setting, and internal policy and procedures

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Role of Healthcare Professionals in Documentation

Allied Health Professionals

Many follow treatment plan developed by the patient’s physician or a therapist or technologist

Documents treatment and patient’s response

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HIM and Documentation

Plays vital and different roles in the overall governance of health record information

Manages many aspects of the health record and its content

Used in coding, billing, and other HIM functions

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HIM Roles

Clinical documentation integrity coordinator

Analyst

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Project Presentation

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