Project Presentation
Gwadys
Chapter42.pptxCHAPTER 4
HEALTH RECORD CONTENT AND DOCUMENTATION
Role of Documentation
Documentation is a communication tool between and among healthcare providers. It is the recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregivers.
Impacts of poor documentation: poor outcomes, issues with patient care, issues with the accuracy of diagnosis and procedure codes, and errors on healthcare claims.
It allows for continuity in the care and treatment of the patient from one healthcare provider to the next and creates a permanent health record for all future care of the patient.
When the documentation is of the appropriate quality, it serves as proof of care and services and demonstrates that documentation standards are met (or not met).
Documentation Standards
A Standard: 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.
Documentation Standards: Describes those principles, codes, beliefs, guidelines, and regulations that guide healthcare documentation.
The basis of healthcare-related documentation standards is to promote healthcare quality and safety, as well as provide for optimized continuity of care for the patient.
Documentation Standards
Documentation standards have grown in complexity and detail over time
Multiple sources of documentation standards:
Insurance company or payers
Government regulatory agencies
Licensing boards
Accrediting bodies
Facility policies and procedures
Medical staff bylaws
Medical Staff Bylaws
A healthcare organization medical staff bylaws are the standards that govern 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.
Accreditation organization: measure the compliance of the healthcare organization with the standards developed by the accreditation organization.
Licensure organization: are the legal authority or formal permission from the authorities to carry out certain activities that require such permission - e.g a hospital cannot treat patients without being licensed by the state.
Medical Staff
Medical Staff
Group of physicians and nonphysician providers, who have privileges to practice medicine at a particular healthcare organization.
Medical Staff Privileges:
Specific services and procedures that the medical staff member is deemed qualified to perform, at a particular healthcare provider organization.
Accreditation
A voluntary process. Periodical evaluation against pre-established written criteria. Healthcare organizations measure their own compliance with standards.
Healthcare organizations that are accredited by an approved accreditation organization are exempt from routine state survey agencies.
The Healthcare Facilities Accreditation Program (HFAP) was initially created to evaluate osteopathic hospitals.
The Commission on Accreditation of Rehabilitation Facilities (CARF) was established in the 1960s as an independent, nonprofit accrediting organization to meet the survey needs of the various rehabilitation-based healthcare providers.
Joint Commission
Joint Commission provides accreditation for:
Ambulatory healthcare
Behavioral health
Critical access hospital
Homecare
Hospital
Laboratory
Nursing care centers
Physician offices
Office-based surgery centers
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.
Legal Health Record: Documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information.
Authentication
This is the process of identifying the source of health record entries by attaching a handwritten signature, the author’s initials, or an electronic signature.
Auto-Authentication: is a procedure that allows dictated reports to be considered automatically signed unless the HIM department is notified of needed revisions within a certain time limit.
Despite different settings in which healthcare can be provided, healthcare records contain two distinct types of information: clinician and administrative.
Inpatient Health Record
Inpatient Health Record: is generated when a patient is provided with room, board, and continuous general nursing care in an area of an acute-care healthcare organization.
Clinical data: is the information that reflects the treatment and services provided to the patient as well as how the patient responded to such treatment and services.
Physical Examination: represents the physician’s assessment of the patient’s current health status after evaluating the patient’s physical condition.
Special Health Records
Some health records have unique requirements because of the specialized services provided:
Obstetric and Newborn Health Record
Ambulatory Health Record – General
Ambulatory Surgery Record
Ancillary Departments
Physician Office Record
Long-Term Care
Rehabilitation
Behavioral Health
Home Health
