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Assignment 3: answer questions real world case 4.1; At least one page; cite textbook and or other sources; please textbook below

Real-World Case 4.1

The hospital clinical documentation improvement (CDI) specialist reports to you, the HIM manager of Anywhere hospital, that the hospital has been receiving reimbursement penalties. The physician documentation is not appropriately identifying specific conditions that CMS has identified as hospital-acquired conditions (HACs). In most cases, these conditions are present in patients before they are admitted. However, physicians are documenting these conditions later in the patients’ stays, making it appear that the patients have ­acquired these conditions from the hospital. The hospital is being financially penalized because these conditions are considered to be preventable if the hospital follows national treatment standards and guidelines.

Anywhere hospital has a robust EHR. Many ­documentation improvement initiatives have been leveraged by the technological capabilities of the EHR. As the HIM manager, you wonder if something could be done from a technology standpoint that could assist physicians with identifying, upon admission, those conditions that are causing the reimbursement issue, and appropriately documenting the conditions. Physicians appropriately capturing and documenting these conditions would demonstrate that the hospital is following the national treatment standards and guidelines and the patients are not acquiring these conditions in the hospital.

You assemble a multidisciplinary team consisting of physicians, revenue cycle representatives, HIM, and information systems representation.

Real-World Case 4.1

Why do you think that CMS picked these conditions?

What is the benefit of developing an EMR solution for this issue?

How does the adherence to the treatment guidelines for the prevention of the conditions identified as hospital-acquired relate to other pay-for-performance initiatives?

Assignment 2: answer questions real world case 4.2; at least one page; cite textbook and or other sources; please see textbook below

Real-World Case 4.1

Why do you think that CMS Aaed these condions?

What is the bene<t of developing an EMR soluon for this issu Assignment 4: answer questions real world case 4.2 at least one page; cite textbook and or other sources. Please see textbook below

Real-World Case 4.2

You are a HIM professional working in Anywhere hospital’s HIM department. You have been asked to review physician documentation within the hospital’s new EHR system, implemented six months ago. The goal of the review is to catch any documentation issues early and work with the appropriate hospital leadership to fix those issues.

As you review the documentation in the EHR, you notice that physicians are utilizing the copy and paste functionality available in the EHR, which allows them to select health record documentation from one source or section of the EHR and replicate it in another source or section of the EHR. In one instance the health record identifies a patient as a 65-year-old male (as identified during the registration process), but in the progress notes the patient is described as a 25-year-old female who has given birth. Clearly, the physician utilized the copy and paste functionality inappropriately and accidentally copied health record information from the health record of a 25-year-old female and pasted that information into the health record of a 65-year-old male.

This type of error could have patient safety concerns, as well as billing and claims issues, and the use of this functionality could open up the facility to potential claims of fraud and abuse by the payer. You take this concern to your leadership and a multidisciplinary group of hospital employees including HIM professionals, nurses, physicians, and billing and revenue cycle employees to discuss and fix the problem. There are mixed opinions about the copy and paste functionality. Some individuals feel this feature is a time-saver and a productivity booster while others believe it only opens the hospital up to additional CMS scrutiny.

Real-World Case 4.2

What should be considered when deciding whether or not to use the copy and paste functionality?

What controls might be put in place related to the copy and paste functionality?

What alternatives to the copy and paste functionality are available?

Health Information Management Technology,

An Applied Approach

Nanette Sayles, Leslie Gordon

Copyright ©2020 by the American Health Information Management Association. All rights reserved. Except as permitted under the Copyright Act of 1976, no part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, photocopying, recording, or otherwise, without the prior written permission of AHIMA, 233 North Michigan Avenue, 21st Floor, Chicago, Illinois 60601-5809 (http://www.ahima.org/reprint).

ISBN: 978-1-58426-720-1

AHIMA Product No.: AB103118

Chapter 4

Health Record Content and Documentation

The saying “If it wasn’t documented, it wasn’t done (or didn’t happen)” succinctly conveys the level of importance all healthcare providers should place on health record documentation. Documentation is the recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregivers. Documentation takes various forms within the health record. Examples of health record documentation ­include progress notes, laboratory test results, radiology imaging reports, and operative reports, all of which provide a complete medical picture of the patient. The health record centralizes documentation regarding a patient’s healthcare visit and treatment history in an official, permanent, and recorded format. For thousands of years, individuals have been documenting stories and events in written form to share and reshare with future generations. Healthcare documentation is no exception. The health record, specifically the documentation maintained within it, has historically allowed and presently enables the patient’s healthcare providers to make well-informed concurrent treatment decisions for the patient and establishes a healthcare history for the patient for future reference.

It is important not only that there is documentation within the health record but that the documentation itself is appropriate, accurate, reliable, and readily accessible. Data quality is the reliability and effectiveness of data for its intended uses in operations, decision-making, and planning. Complete and accurate health record documentation drives high-quality patient care as well as appropriate coding and claims submission, resulting in appropriate reimbursement. Data quality applies not only to health record (clinical) information but also to billing and claims data, administrative and business data, and disease registry data. Documentation must be complete and accurate, support quality initiatives, and meet accreditation requirements. Chapter 6, Data Management, will address data quality in more depth.

When health record documentation is lacking in accuracy, reliability, and effectiveness, it may fail to appropriately describe the care and treatment of the patient. This lack of data quality can impact the quality of care the patient receives. Poor documentation impacts the assessment and evaluation of the patient and the communication among healthcare providers, results in medical errors, and contributes to poor patient outcomes. Poor documentation also impacts the accuracy of medical coding due to potential improper code assignment, resulting in inaccurate diagnosis and procedure codes. Inaccurate coding impacts billing, reimbursement, and claims submission for the care and treatment provided to the patient. If poor-quality documentation affects the accuracy of coding, billing, and claims submission, then state and federal regulatory compliance and accreditation standards of the healthcare organization can also be in jeopardy.

Role of Documentation

Health record documentation plays a variety of roles within the clinical healthcare setting. Documentation is a communication tool between and among healthcare providers. 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. The documentation that is generated during the care and treatment of the patient is the starting point for the revenue cycle, which facilitates the coding and billing of the care and treatment. 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). The next section will discuss the principles, codes and beliefs, and guidelines related to documentation standards.

Documentation Standards

A standard is 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. Standards must be based on generally accepted rules of the healthcare industry. Within the context of healthcare, documentation standards describe those principles, codes, beliefs, guidelines, and regulations that guide health record documentation. Documentation standards dictate how healthcare providers should document the treatment and services (rendered to the patient) within the health record. The basis for healthcare-related documentation standards is to promote healthcare quality and safety, as well as provide for optimized continuity of care for the patient. As the health record and health record documentation have become more computer based, documentation standards have become even more important, not only from a clinical documentation standpoint but also from an organizational standpoint. How health record documentation is used within the electronic health record (EHR) has become a focus of many health information management (HIM) professionals.

When the EHR first began replacing traditional paper-based health records, a common belief was that the standards addressing the documentation contained within the EHR (covered in chapter 11, Health Information Technologies) were somehow ­different from those standards addressing the ­documentation in a paper-based health record. This belief is incorrect. In general, the standards that traditionally applied to paper-based documentation hold true for documentation generated and maintained within the EHR. As healthcare providers have come to realize the great benefits of EHR technologies as they relate to documentation quality and overall patient safety, those same technologies have also presented some challenges. One example is the use of a template. A template is a pattern used in EHRs to capture data in a structured manner and specify the information to be collected. For example, a birth record template would require data such as date of birth, time of birth, APGAR scores, length, weight, and so forth. It helps the care provider ensure key information is not forgotten. It also certifies that the data are captured in a specific order and format. Whether the patient’s health record is electronic or paper-based, accurate and appropriate documentation is key to meeting compliance standards—namely, those for medical necessity and the justification for treating the patient.

Standards

Over the years, documentation standards have become more detailed and focused on patient care quality, appropriate reimbursement, and the prevention of fraud and abuse from a regulatory perspective. The Centers for Medicare and Medicaid Services (CMS) defines fraud as 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 some other person(s) and abuse describes practices that either directly or indirectly result in unnecessary costs to the Medicare Program (CMS 2017). Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are priced fairly. (See chapter 16, Fraud and Abuse Compliance, for more discussion on fraud and abuse.) The application of the standards varies depending upon the content of the health record; whether the record is an inpatient, ambulatory, behavioral health, or physician office record; and from where the standards originate. Sources for standards include insurance companies and payers, government regulatory agencies, licensing boards, accrediting bodies, healthcare organization policies and procedures, and healthcare provider organization medical staff bylaws.

With the healthcare industry focusing on patient care quality, appropriate reimbursement, and the prevention of fraud and abuse, the 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. This provides an inherent level of acceptable quality so other healthcare providers have a clear and accurate understanding of the patient’s condition and how the patient is responding to treatment. In addition, documentation standards drive appropriate healthcare reimbursement through accurate code capture during the revenue cycle process, reducing the chances that inaccurate or fraudulent claims are processed and sent to commercial or governmental payers for reimbursement.

Medical Staff Bylaws

A healthcare organization’s medical staff bylaws are the standards that govern the practice of medical staff members. These medicals staff bylaws are typically voted upon by the organized medical staff and the medical staff executive committee and ­approved by the healthcare organization’s board of directors. They play an important role in documentation standard mandates and development. Accreditation organizations measure the compliance of the healthcare organization with the standards developed by the accreditation organization. Licensure organizations are the legal authority or formal permission from the authorities to carry out certain activities that require such permission. For example, a hospital cannot treat patients without being licensed by the state. Federal and state regulatory agencies mandate the content, specifically the breadth and depth of these bylaws, as well as the application of the bylaws. Medical staff bylaws vary slightly from one healthcare organization to another as a result of differences in state laws and the needs of individual healthcare organizations. Before addressing medical staff bylaws, it is important to understand the function and responsibility of a healthcare organization’s medical staff.

A healthcare organization’s medical staff is a group of physicians and nonphysicians such as nurse practitioners and physician assistants who have medical staff privileges. Medical staff personnel go through a process that ensures the physician or other healthcare professional has the education and qualifications required to perform services and procedures in a healthcare organization. The result is a specific list of services and procedures (medical staff privileges) that the medical staff member may perform at a particular healthcare provider organization. The medical staff bylaws govern the business conduct, rights, and responsibilities of the medical staff; medical staff members must abide by the bylaws to practice in the healthcare organization. It is through the process of granting medical staff privileges and enforcing the medical staff bylaws that the overall quality of care and treatment provided to patients is governed (Adelman 2012). Credentialing is the process of reviewing and validating the qualifications (degrees, licenses, and other credentials) of physicians and other licensed independent practitioners for granting medical staff privileges to provide patient care services (AAFP 2019).

A number of accrediting, licensing, and regulatory entities drive the configuration of the medical staff and the content and application of the medical staff bylaws of a healthcare organization. The Centers for Medicare and Medicaid Services (CMS) is the federal agency within the Department of Health and Human Services (HHS) known for its operational oversight of the Medicare and Medicaid programs. The Joint Commission also plays an important regulatory role in a healthcare organization’s medical staff makeup and the content of the medical staff bylaws by establishing standards for the medical staff bylaws. The Joint Commission is a common accreditation organization for hospitals and other healthcare organizations. (The Joint Commission is covered in more detail later in this chapter.)

Content required in medical staff bylaws includes the healthcare provider organization’s processes for self-governance and general oversight obligations, due process rights as they relate to potential disciplinary action, peer review policies and procedures, and medical staff appointment, privileging, and credentialing (CMS 2018). CMS mandates the medical staff bylaws must do the following:

· Be approved by the governing body of the medical staff

· Address the duties and privileges of each type of medical staff member

· Describe the organization of the medical staff

· Describe the qualifications that must be met by any individual wishing to seek appointment to the medical staff (42 CFR 482.22(c))

CMS dictates that medical staff bylaws must address certain documentation requirements in the Medicare Conditions of Participation. The Medicare Conditions of Participation (CoP) are the standards that a healthcare organization must meet to receive Medicare funding. One of the requirements is that a medical history and physical (H&P) be documented for every patient no more than 30 days before or 24 hours after admission to the hospital. The H&P contains pertinent information about the patient, including chief complaint, past and present illnesses, family history, social history, and review of body systems, and must be documented in the health record prior to any surgery or procedure requiring the patient to receive anesthesia. If, however, the physical exam is completed within the 30 days of a surgery or procedure, an updated exam must be documented within 24 hours of admission and prior to the surgery or procedure. This updated exam must include any changes in the patient’s condition since the time of the first exam (42 CFR 482.22(c)).

Accreditation

Accreditation is a voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entity’s work against pre-established written criteria. CMS CoPs and Conditions for Coverage (CfCs) ensure patient care quality, safety, and improvement of clinical outcomes. CfCs are standards applied to healthcare organizations that choose to participate in federal government reimbursement programs such as Medicare and Medicaid (Ambulatory Surgery Center Association n.d.). For a healthcare provider to participate in federal government reimbursement programs, the healthcare provider must demonstrate they at least meet, or exceed, the CoPs and CfCs.

Auditing and monitoring are the main ways state and federal government measure a healthcare provider’s compliance with the CoP and CfC standards and criteria. Healthcare providers that are accredited by an approved accreditation organization are exempt from direct government auditing and monitoring. The accreditation organization must go through its own CMS review to receive deemed status. Deemed status is an official designation indicating that a healthcare organization complies with the Medicare Conditions of Participation (ASHE n.d.). It is through this deemed status that the accreditation organization is permitted to evaluate other healthcare provider organizations for CoP and CfC compliance through its accreditation process. Currently nine national accreditation organizations have obtained deemed status and are responsible for surveying healthcare providers who are currently participating in the Medicare and Medicaid programs (see table 4.1).

Many healthcare providers seek accreditation because it gives the healthcare organization an opportunity to measure its own compliance as well as see what operational improvements it can make based upon the findings of the accreditation organization. Patients also want to know that the healthcare provider they entrust with their care complies with quality and clinical outcome measures. Accreditation enhances reputation among healthcare organizations that take part in the process. In most cases the accreditation process is voluntary, but the healthcare organization must be accredited by an accreditation organization to participate in specific programs and services. This is true for the Medicare and Medicaid programs. Because of the vast number of specialties within healthcare, there are a number of accreditation organizations that specialize in the surveying of particular types of healthcare facilities. These include:

· Healthcare Organizations Accreditation Program

· Commission on Accreditation of Rehabilitation Facilities

· Accreditation Association for Ambulatory Healthcare

· Joint Commission

Table 4.1 CMS-approved accrediting organizations

Accreditation organization	Program
Accreditation Association for Ambulatory Health Care (AAAHC)	Ambulatory surgery centers
Accreditation Commission for Health Care (ACHC)	Home health, hospice
American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)	Ambulatory surgery centers, occupational therapy, rural health clinics
American Osteopathic Association/Healthcare Facilities Accreditation Program (HFAP)	Ambulatory surgery centers, critical access hospitals, hospital
Center for Improvement in Healthcare Quality (CIHQ)	Hospital
Community Health Accreditation Program (CHAP)	Home health, hospice
DNV GL Healthcare	Critical access hospitals, hospital
The Compliance Team	Rural health clinics
Joint Commission	Ambulatory surgery centers, critical access hospitals, hospital, home health, hospice, psychiatric hospital

Source: Adapted from Centers for Medicare and Medicaid Services, CMS 2018.

The Healthcare Facilities Accreditation Program (HFAP) was initially created to evaluate osteopathic hospitals. A doctor of osteopathic medicine as well as a healthcare organization that identifies as an osteopathic entity, maintain a different philosophical and clinical approach to caring for the patient compared to the conventional (allopathic) approach to medicine. Due to these differences, these healthcare providers required a slightly different accreditation survey process. However, over time, HFAP began to evaluate all healthcare providers. Similar to other accreditation organizations, the requirements that healthcare providers must meet are based upon, for the most part, the CoPs. Most of the surveyors who perform the HFAP surveys are healthcare professionals themselves and survey and subsequently accredit acute-care facilities, critical access facilities, hospitals, ambulatory surgery centers, clinical labs, behavioral health facilities, and office-based surgery.

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 various rehabilitation-based healthcare providers. These rehabilitation-based healthcare providers include independent and nonprofit providers, aging services, behavioral health, and opioid treatment programs. CARF surveys the business operations, clinical processes, and rehabilitation program specialties, and subspecialties for compliance. As with all accreditation organizations, the standards and evaluation methods are regularly reviewed and revised as necessary to meet the ever-changing regulatory standards environment in these areas of healthcare. CARF also assists healthcare providers with establishing best practices in these specialized areas of rehabilitation treatment.

The Accreditation Association for Ambulatory Healthcare (AAAHC) was established in the late 1970s. AAAHC surveys and subsequently accredits various ambulatory-based healthcare providers such as surgery centers, imaging centers, endoscopy centers, and women’s health centers. Because of the variety of ambulatory specialties AAAHC accredits, the surveyor who is sent to survey for compliance typically has expertise in the specialty that is being surveyed. For example, a surveyor who reviews an ambulatory surgery center should have experience at an ambulatory surgery center. AAAHC’s focus is on establishing, reviewing, and revising standards as well as measuring performance and providing education to those healthcare providers it surveys. The surveys evaluate the facility infrastructure and safety, as well as business operations, clinical operations, and patient documentation for compliance.

Joint Commission

The Joint Commission has already been introduced in this chapter. Although there are many high-quality accreditation organizations in existence today, all with the common goals of patient safety and the delivery of high-quality healthcare to patients, the Joint Commission has been an ­industry leader in the area of healthcare accreditation. The Joint Commission also provides organizations it accredits with education and compliance outreach services.

Over the years, the Joint Commission has expanded its accreditation program offerings and currently provides accreditation for ambulatory healthcare, behavioral health, critical access hospitals, home care, hospital, laboratory, nursing care centers, physician offices, and office-based surgery centers. In addition to the different types of healthcare provider organizations that can seek and obtain Joint Commission accreditation, specific programs addressing specific disease processes can also obtain accreditation through the Joint Commission certification process (Joint Commission 2016a).

Certification is the process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements. The more commonly known programs that often obtain certification address asthma, diabetes, and heart failure (Joint Commission 2016b–d).

Compliance, quality, and patient safety have become the focal points of the healthcare industry’s clinical and operational practices. The Joint Commission responded to this shift in focus by moving from announced reviews that occurred once every three years to unannounced reviews, coupled with changes to the review process itself. The Joint Commission provides organizations that choose to obtain or maintain their accreditation with an accreditation manual. The manual is comprised of chapters addressing various areas of clinical and operational practice, including but not limited to:

· Environment of Care

· Leadership

· Provision of Care, Treatment, and Services

· Life Safety

· Information Management (Joint Commission 2016e)

The chapters in the Joint Commission accreditation manual contain specific standards and elements that describe in detail the continuous compliance expectations for the healthcare organization. Each standard and element has a corresponding explanation and scoring procedure ­associated with it. For example, within the Infection Control chapter, the Joint Commission describes when a healthcare provider should wear a gown when caring for a patient (contact precautions). When contact precautions are initiated, the Joint Commission expects that such activity will be documented appropriately in the patient’s health record.

The Joint Commission emphasizes appropriate and standardized health record documentation. Those standards and elements address health record content, legibility and completeness, dating and timing of entries, order sets, abbreviations, history and physical component requirements, and informed consent, among many other standards and elements.

State Statutes

A statute is a piece of legislation written and approved by a state or federal legislature and then signed into law by the state’s governor, or the President of the United States. State statutes, as they relate to health record documentation, vary by state in terms of what components of health record documentation are regulated and to what degree it is regulated by law. In many instances, state statutes address the documentation ­requirements according to the type of health record. For example, Ohio law addresses the specific documentation requirements for inpatient psychiatric service providers. For example, the Ohio Administrative Code describes how involved a patient should be in involved his or her care plan and how the care plan should be documented.

Legal Health Record

In the past, the terms health record and legal health record were used interchangeably, and the subtle nuances of these two terms provided little impact to the operations of a healthcare provider. The legal health record is the documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information. Identifying the legal health record was simple when health records were primarily paper-based and included the contents of the paper health record in addition to diagnostic radiographic films or x-rays. During this time, the health record and the legal health record were one and the same. The legal health record became complicated when electronic health ­record technology was adopted and healthcare provider organizations moved from a strictly paper-based record to a more hybrid record model, and then to a fully electronic format since the health record became scattered and more information was available.

The current definition of the legal health record is complicated. Each healthcare organization must define what its legal health record contains. The legal health record is used to ensure compliance with laws and regulations, healthcare policies, accreditation standards, and any other requirements (HIMSS n.d.). Healthcare organizations with an EHR must determine what to do with health records that they receive from other healthcare providers. At one time, it was standard practice for a healthcare organization to incorporate another provider’s health record into the legal health record and release that documentation as part of the healthcare organization’s legal health record. Today, the healthcare organization should consult with legal counsel to assist with making a decision about whether or not to include another provider’s records in the legal health record. Some state laws dictate what can and cannot be included in the healthcare organization’s legal health record and, in many cases, the hospital’s attorney is in the best position to decide whether to include or exclude the records from other providers. For the EHR to be a legal health record and meet the requirements, several concepts need to be considered. These concepts include how documentation is actually created and signed by healthcare providers; how the documentation is managed and preserved; how the documentation impacts and interacts with the revenue cycle functions of billing and claims submission; and how the documentation is displayed both electronically to the user as well as in hard copy form, should the data be printed (HIMSS 2011). Once a healthcare organization defines its legal health record, necessary policies and procedures should be developed to formalize the healthcare organization’s approach to defining the health record. See chapter 8, Health Law, for more information about the legal health record.

General Documentation Guidelines

General documentation guidelines apply to all categories of health records. These guidelines address the uniformity, accuracy, completeness, legibility, authenticity, timeliness, frequency, and format of health record entries. The American Health Information Management Association (AHIMA) developed the following general documentation guidelines:

· Every healthcare organization should have policies that ensure the uniformity of both the content and the format of the health record. The policies should be based on all applicable accreditation standards, federal and state regulations, payer requirements, and professional practice standards.

· The health record should be organized systematically to facilitate data retrieval and compilation.

· Only individuals (physicians, nurses, physical therapists, and more) authorized by the healthcare organization’s policies should be allowed to enter documentation in the health record.

· Organizational policy and 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 described are rendered.

· The authors of all entries should be clearly identified in the health record.

· Only abbreviations and symbols approved by the organization and medical staff rules and regulations should be used in the health record.

· All entries in the health record should be permanent (written in permanent ink).

· Errors in paper-based records should be corrected according to the following process: Draw a single line in ink through the incorrect entry. Then print the word “error” at the top of the entry along with a legal signature or initials, the date, time, and reason for change, and the title and discipline of the individual making the correction. The correct information is then added to the entry. Errors must never be obliterated. The original entry should remain legible, and the corrections should be entered in chronological order. Any late entries should be labeled as such.

· Any corrections or information added to the health record by the patient should be inserted as an addendum (a separate note). No changes should be made in the original entries in the record. Any information added to the health record by the patient should be clearly identified as a patient addendum (Smith 2001, 56).

· When errors in the EHR are corrected, the erroneous information should not be displayed; however, there should be a method to view the previous version of the document with the original data (Wiedemann 2010).

From a governmental regulatory perspective, CMS and federal regulations also address what would be considered general documentation guidelines and further explain what this guidance means.

· All health record entries must be legible. Orders, progress notes, nursing notes, or other entries in the health record that are not legible may be misread or misinterpreted and may lead to medical errors or other adverse patient events.

· All entries in the health record must be complete. A health record is considered complete if it contains enough information to identify the patient; support the diagnosis or condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among healthcare providers.

· The time and date of each entry (orders, reports, notes) must be accurately documented. Timing establishes when an order was given, when an activity happened, or when an activity is to occur. Entries must be timed and dated for patient safety and quality of care. Timed and dated entries establish a baseline for future actions or assessments and establishes a timeline of events.

· There must be a method to establish the identity of the author of each entry.

There must be a method to require that each author takes a specific action to verify that the entry being authenticated is his or her entry or that he or she is responsible for the entry and the entry is accurate (42 CFR 482.24(c)(1)).

Authentication is the process of identifying the source of health record entries by attaching a handwritten signature, the author’s initials, or an electronic signature. CMS defines what authentication methods are to be used for health record entries such as written signatures, initials, computer key, or other code; the requirements a healthcare ­provider needs to have in place; and controls to prevent any changes from being made to the health record after the entries have been authenticated (42 CFR 482.24(c)(1)).

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 or a process by which the failure of an author to review and affirmatively approve or disapprove an entry within a specified time period results in authentication. For example, a physician dictates an operation, the operative report is transcribed, but the physician never accesses the report to review it for accuracy and completeness. The EHR system is set up to show the physician signed the operative report even though he or she never reviewed the document. Auto-authentication does not meet standards for appropriate timing, dating, and signing-off of documentation by healthcare providers and therefore should not be used.

Documentation by Settings

Despite different settings in which healthcare can be provided—hospitals, ambulatory surgery centers, physician offices, long-term care facilities—health records contain two distinct types of information: clinical and administrative (defined later in the chapter). A healthcare organization must maintain a health record on every patient whom they treat. Hospitals frequently use a centralized health record. Having all patient care records stored together enables physicians and other healthcare providers to see the documentation of all the care provided to the patient by others. In a centralized health record, the inpatient and outpatient health record documentation is maintained in one health record rather than in separate health records. Whether the health record is paper-based, electronic, or hybrid, there are distinct differences in the documentation found in the health record. Inpatient, emergency department, ambulatory, ambulatory surgery, ancillary, physician office, long-term care, rehabilitation, and ­behavioral health settings are discussed in more detail in the section that follows.

Inpatient Health Record

The 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, such as a hospital, where the patient generally stays overnight at that healthcare organization. The documents typically found in an inpatient health record include but are not limited to history and physical (H&P), consultation reports, physician’s orders and progress notes, nursing assessments and progress notes, as well as a discharge summary. Over the years, there has been a dramatic shift in the delivery of healthcare treatment and services. Many services such as surgery, infusions, and other diagnostic procedures that once required a patient to stay overnight in the hospital can be performed on an outpatient basis. Only the most severely ill patients and the most invasive procedures require an overnight stay and therefore the inpatient health record is the most complex. A discussion of the three major health records categories within the inpatient care services continuum (medical and surgical, obstetric, and newborn) follows.

Medical and Surgical

The medical and surgical health record is found in a variety of settings including inpatient care units, long-term care facilities, home health, surgical centers, and ambulatory care units. Medical and surgical health record documentation pertains to adult patients with various acute and active disease processes or injuries. The medical and surgical health record contains documentation originating from physicians, nurses, diagnostic procedures, as well as from the dietary, pharmacy, social services, and other departments. The categories of information found in the medical and surgical record include clinical data, administrative data, and consents, authorizations, and acknowledgments. Consents and authorizations are discussed in chapter 8. An acknowledgment is a document that the patient’ or the patient’s authorized personal representative sign, confirming the receipt of important information.

Clinical Data 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; it is also the basis for the reimbursement of the treatment and ­service rendered to the patient. The clinical data portion of the acute-care record constitutes the largest ­portion of the health record and consists of nine separate and distinct parts. These parts are: medical history, physical exam, diagnostic and therapeutic procedure orders, clinical observations, diagnostic and procedure reports, surgical procedure documentation, consultation report, discharge summary, and patient instructions and transfer record.

Medical History The medical history portion of clinical data addresses the patient’s current complaints and symptoms and describes his or her past medical, personal, and family history. In inpatient care, the medical history is the responsibility of the attending physician. The history generally focuses on the body systems involved in the patient’s current illness. Table 4.2 shows the information that is usually included in a medical history.

Physical Examination The physical examination represents the physician’s assessment of the patient’s current health status after evaluating the patient’s physical condition. The physician performs the physical examination to ensure appropriate treatment and services are ordered for the patient. Table 4.3 lists the components of the physical examination documentation. Together the medical history and physical examination are commonly referred to as the history and physical (H&P).

CMS guidance and regulations, Joint Commission standards, and healthcare organization policies and procedures will dictate when the medical history and physical exam must be completed by the physician. There are also documentation standards that address when a previously completed H&P can be utilized when a patient is admitted to the hospital (discussed later in this chapter).

Diagnostic and Therapeutic Procedure Orders There are many diagnostic and therapeutic order types. Diagnostic orders include orders for x-rays, CT, MRI, lab tests, and more for the purpose of diagnosing a patient’s symptoms of ­illness. Therapeutic orders are orders for treatment that either prevent or address illness by way of medication administration, surgery, or counseling. Physician orders are the instructions the physician gives to other healthcare professionals who perform diagnostic tests and treatments, administer medications, and provide specific services to a particular patient. For example, the physician might order a nurse to take the patient’s temperature every two hours. Admission and discharge orders should be found for every patient unless the patient leaves the healthcare organizations against medical advice (AMA), but other orders will vary from patient to patient. All orders must be legible and include the date and the physician’s signature. In electronic systems, signatures are attached via an authentication process discussed in chapter 10, Data Security.

Standing orders are orders the medical staff or an individual physician established as routine care for a specific diagnosis or procedure. Standing orders authorize other healthcare providers (such as nurses) to begin treating the patient ­before the physician examines the patient. Standing orders are commonly used for disease processes and injuries requiring prompt attention. For example, a standing order to all the physician’s patients who are scheduled for an appendectomy would include all the orders commonly needed to get the patient ready for surgery. The physician can then add orders that are specific to a patient; for example, a patient who is scheduled for an appendectomy and who is also diabetic will have different standing orders than a patient with no underlying disease process. Like other physician orders, the standing orders must be signed, verified, and dated.

Physicians may communicate orders verbally or via telephone when the hospital’s medical staff rules allow. State law and medical staff rules specify which practitioners can accept and execute ­verbal and telephone orders (for example, only registered nurses). How the orders are to be signed as well as the time period allowed for authentication also may be specified. Currently, there is technology that allows orders to be sent via mobile devices, such as smart phones and tablets, and healthcare organizations are beginning to explore the possibility of using this technology.

Clinical Observations In acute-care hospitals, the documentation of clinical observations is usually provided in a progress note. Clinical observations are the comments of physicians, nurses, and other caregivers that create a chronological report of the patient’s condition and response to treatment during his or her hospital stay. Progress notes serve to justify further acute-care treatment in healthcare organizations. In addition, the progress notes document the appropriateness and coordination of the services provided. The patient’s condition determines the frequency of the notes.

The rules and regulations of the hospital’s medical staff specify which healthcare providers can enter progress notes in the health record. Typically, the patient’s attending physician, consulting physicians who have medical staff privileges, house medical staff, nurses, nutritionists, social workers, and clinical therapists (such as physical therapists) are authorized to enter progress notes. Depending on the health record format used by the hospital, each discipline may maintain a separate section of the health record or the observations of all the providers may be combined in the same chronological or integrated health record. Guidelines for the frequency of notations may also be found in the medical staff rules and regulations.

Special types of notes are frequently found in a health record. For example, prior to the administration of any medication other than local anesthesia, the anesthesiologist visits the patient and documents important factors about the patient’s condition that may have an impact on the anesthesia chosen or its route of administration. Allergies and drug reactions are noted. A post-anesthesia note that describes the patient’s recovery from the anesthetic is required. Similarly, the surgeon ­responsible for a major procedure must document both pre- and post-surgical patient evaluations.

In the case of a death, the attending physician should add a summary statement to the patient’s health record to document the circumstances surrounding the patient’s death. The statement can take the form of a final progress note or a separate report. The statement should indicate the reason for the patient’s admission, his or her diagnosis and course in the hospital, and a description of the events that led to his or her death.

Just as physician documentation begins with the H&P, nurses and allied health professionals may begin their care with assessments focused on understanding the patient’s condition from the perspective of their specialized body of knowledge. Often a care plan— 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. In addition, nurses are responsible for specific patient admission and discharge notes and for documenting the patient’s condition at regular intervals throughout the patient’s stay. If a patient should die while hospitalized, nursing notes regarding the circumstances leading to and of death are important for quality and patient health outcomes improvement, risk management activities, and, in some cases, payer reimbursement considerations.

In certain situations, when the patient has died, an autopsy may be requested or required and a subsequent autopsy report, a description of the examination of a patient’s body after he or she has died, is completed. Also called necropsies, autopsies are usually conducted when there is some question about the cause of death or when information is needed for educational or legal purposes. The purpose of the autopsy is to determine or confirm the cause of death or to provide more information about the course of the patient’s disease.

The autopsy report is completed by a pathologist and becomes part of the patient’s health record. The autopsy report content and the format of the content is standardized and governed by the National Association of Medical Examiners. Every autopsy report contains the diagnosis, toxicology, opinion, circumstances of death, identification of the decedent, general description of clothing and personal effects, evidence of medical intervention, external examination, external evidence of injury, internal examination, and samples obtained. ­Because reports from tissue examination or laboratory testing can take weeks or even months, a preliminary report including preliminary diagnoses is often documented until findings are received and the final report is completed. The authorization for the autopsy, signed by the patient’s next of kin or by law enforcement authorities, must be obtained prior to the autopsy and should become part of the record.

Nursing professionals also maintain chronological records of the patient’s vital signs (blood pressure, heart rate, respiration rate, and temperature) and documentation of medications ordered and administered. Other chronological monitors such as measures of a patient’s fluid input and output may be ordered and recorded depending on the patient’s diagnosis. Sometimes these records are referred to as flow records because they show trends over time, or the data may be represented in graphic form for ease of communication. Special interventions such as the use of restraints also require documentation. For example, restraint information must include the type of restraint used, time frame used, and regular vital sign monitors and descriptions of the patient’s physical condition while restrained.

After an initial assessment, documentation by other allied health professionals varies by specialty. Each healthcare organization will define the appropriate content and frequency of documentation based on specific regulations and standards and the profession’s practice guidelines. For example, respiratory therapy treatments may be documented via progress notes and social work interventions may appear as dictated reports.

Diagnostic and Therapeutic Procedure Reports The results of all diagnostic and therapeutic procedures become part of the patient’s health record. Diagnostic procedures include the following:

· Laboratory tests performed on blood, urine, and other body fluids

· Pathological examinations of tissue samples and tissues or organs removed during surgical procedures

· Imaging procedures of the patient’s body and specific organs (radiology, scans, ultrasounds, MRIs, PETs)

· Monitors and tracings of body functions

The results of most laboratory procedures are generated electronically by automated testing equipment. In contrast, the results of monitors, imaging, and pathology procedures require interpretation by specially trained physicians such as cardiologists, radiologists, and pathologists. These physicians document their findings in reports that then become part of the patient’s permanent record, along with copies or samples of the tracing, images, and scans.

Surgical Procedure Documentation Any surgical procedure requires special documentation. Preoperative notes are made by the anesthesiologist and surgeon prior to the procedure, and nurses report preoperative patient preparations. The entire procedure itself is then recorded, along with an anesthesia record, an operative report, and a post-anesthesia or recovery room report. When tissue is removed for evaluation, a pathology report also must be present.

The anesthesia report notes any preoperative medication and the response to it, the dosage of the anesthesia administered and the route of administration, the duration of administration, the patient’s vital signs while under anesthesia, and any blood products administered to the patient during the procedure, and other preoperative information. The anesthesiologist or nurse anesthetist is responsible for this documentation.

The operative report describes in detail the surgical procedures performed on the patient. The content of the operative report is found in table 4.4.

Table 4.4 Content of the operative report

• Patient’s preoperative and postoperative diagnosis

• Descriptions of the procedure(s) performed

• Descriptions of all normal and abnormal findings

• Description of the patient’s medical condition before, during, and after the surgical procedure

• Estimated blood loss

• Descriptions of any specimens removed

• Descriptions of any unique or unusual events during the surgical procedure

• Names of the surgeons and their assistants

• Date and duration of the surgical procedure

Source: ©AHIMA.

The operative report should be written or dictated by the surgeon immediately after surgery and become part of the health record as soon as possible. When there is a delay in dictation or transcription, a progress note describing the surgery should be entered into the patient’s health record. Reports of non-surgical other procedures or treatments will require documentation as well. These may include administration of blood transfusions, chemotherapy documentation, and more.

Immediately after the procedure, the patient is evaluated for a period of time in a special unit called a recovery room. Monitoring is important to ensure the patient sufficiently recovers from the anesthesia and is stable enough to be moved to another location. The recovery room report includes the post-anesthesia note (if not found elsewhere), nurses’ notes regarding the patient’s condition and surgical site, vital signs, intravenous fluids, and other medical monitoring.

A pathology report is dictated by a pathologist after examination of tissue received for evaluation. This report usually includes descriptions of the tissue from a gross or macroscopic (with the eye) level and representative cells at the microscopic level along with interpretive findings. Sometimes an initial tissue evaluation occurs while the surgery is in progress to give the surgeon information important to the remainder of the operation. A full written pathology report would follow.

Consultation Reports The consultation report documents the clinical opinion of a physician other than the primary or attending physician. The consultation is usually requested by the primary or attending physician, but occasionally may be the request of the patient or the patient’s family. The consultation report is based on the consulting physician’s examination of the patient and a ­review of the patient’s health record.

Some healthcare organizations allow consultation requests by telephone and provide the ­consultant with selected information from the patient’s health record. The consultant then dictates his or her findings and returns them to the requesting physician.

Discharge Summary The discharge summary is a concise account of the patient’s illness, course of treatment, response to treatment, and condition at the time of patient discharge (official release) from the hospital. The summary also includes instructions for follow-up care to be given to the patient or to his or her caregiver at the time of discharge. Because the summary provides an overview of the entire medical encounter, it is used for a variety of purposes, including the following:

· Ensures the continuity of future care by providing information to the patient’s attending physician, referring physician, and any consulting physicians

· Provides information to support the activities of the medical staff review committee

· Provides concise information that can be used to answer information requests from authorized individuals or entities

The discharge summary is the responsibility of and must be signed by the attending physician. If the patient’s stay is not complicated and lasts less than 48 hours or involves an uncomplicated delivery of a normal newborn, a discharge note in place of a full summary is often acceptable.

Patient Instructions and Transfer Records It is vital that the patient be given clear and concise ­instructions upon discharge, so the recovery progress begun in the hospital continues. Ideally, patient instructions are communicated verbally and in writing. The healthcare professional who delivers the instructions to the patient or caregiver should sign the health record to indicate that he or she has issued them. In addition, the person receiving the instructions should sign to verify that he or she has received and understands them. A copy of these instructions should be filed in the health record.

When someone other than the patient assumes responsibility for the patient’s aftercare, the record should indicate the instructions were given to the responsible party. Documentation of patient education may be accomplished by using formats that prompt the person providing instruction to cover important information.

When a patient is being transferred from the acute setting to another healthcare organization, a transfer record may be initiated. This documentation is also called a referral form. A brief review of the patient’s acute stay along with current status, discharge and transfer orders, and any additional instructions will be noted. Social service and nursing personnel often complete portions of the transfer record.

Administrative Data Administrative data are coded information contained in secondary records (such as billing records) describing patient identification and insurance. Patient registration information would be considered administrative data as would patient account information.

Patient Registration Information Patient registration information includes those data elements obtained during the patient registration process. Most of the patient registration process usually takes place before the physician examines or begins treating the patient. During the registration, process, demographic data are collected. Demographic data are data that identify the patient and includes the following:

· Patient’s full name (including any aliases the patient uses; for example, Bob instead of Robert)

· Patient’s health record number if the patient was not seen at the healthcare organization before. as well as a patient’s account number for this specific visit

· Patient’s address

· Patient’s contact phone number

· Patient’s date of birth

· Patient’s gender

· Patient’s marital status

· Patient’s religious affiliation (if patient has one and chooses to disclose it)

· Race (often this is optional)

· Next of kin information

· Healthcare power of attorney or advance directives (if the patient has these documents) (refer to chapter 8 for specifics)

· If the patient wants to be a private or confidential patient under HIPAA, where the patient opts-out of the healthcare organization’s directory (discussed in chapter 9, Data Privacy and Confidentiality)

Figure 4.1 is an example of demographics in an EHR.

Ambulatory Surgery Record

Ambulatory facilities that perform surgery are called ambulatory surgery centers (ASC). Patients who have surgery in an ASC still must have a history and physical prior to surgery present within the health record. The patient must have signed the appropriate consent documentation prior to the procedure. Much like an inpatient health record containing a surgery component, an ambulatory surgery record must contain operative reports and notes, diagnostic and therapeutic documentation, consultations, and discharge notes at the conclusion of the treatment.

Ambulatory surgery centers will also perform discharge follow-up phone calls, where a nurse will call the patient within 24 to 48 hours postdischarge to check on the patient. The nurse will assess pain levels and address any immediate or future needs of the patient related to the treatment. This conversation must be documented in the health record. The Joint Commission and the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) have requirements applicable to the ambulatory surgery center setting. CMS’s Conditions for Coverage for ambulatory surgical centers govern those that seek Medicare reimbursement.

Ancillary Departments

Ancillary departments are the departments that provide treatment and services that support the patient’s overall care plan. Ancillary departments perform ancillary services—tests and procedures sometimes ordered by a physician—and these services assist the physician with diagnosing and treating the patient. Ancillary departments also consist of departments that play an indirect patient care role but are necessary for the overall management of patient care. These departments include pharmacy, nutrition, HIM, social services, and patient advocacy and patient relations. Many ancillary departmental services must be documented within the patient health record according to the governing standards and regulations within a specific department.

Physician Office Record

Routine healthcare treatment commonly occurs within the physician office setting. Routine services include preventative services such as yearly physicals and blood tests, in addition to diagnosis and treatment of minor illnesses and injuries. In many instances, hospital-based health records can feed into the physician office record if the hospital and physician office records are electronic and information can be exchanged from one health record system to another. Much like a paper-based physician office record, the physician office record that is EHR-based, is often in an integrated health record format.

The physician office record content consists of the following:

· Medical history

· Family history

· Social history

· Vital signs

· Chief complaint

· Progress notes

· Allergies

· Medication list

· History of present illness

· Review of systems

· Assessment and diagnosis

· Plan of treatment

The next section will discuss the regulations that govern long-term care.

Long-Term Care

Long-term care is provided in a variety of healthcare organizations, including skilled nursing facilities (SNFs) or units; subacute-care facilities; nursing facilities (NFs) (nursing homes, long-term care facilities); and assisted-living facilities.

The regulations that govern long-term care facilities vary among these settings. Most SNFs and NFs are governed by both federal and state regulations, including the Medicare CoP. Assisted-living facilities are usually governed only by state regulations. Most long-term care providers do not ­participate in voluntary accreditation programs, although the Joint Commission does have long-term care facility standards.

Because the stay for a patient or resident in long-term settings can be lengthy, health records are based on ongoing assessments and reassessments of the patient’s (or resident’s) needs. An interdisciplinary team develops a plan of care for each patient upon admission to the healthcare organization, and the plan is updated regularly over the patient’s stay. The team includes the patient’s physician and representatives from nursing services, nutritional services, social services, and other specialty areas (such as physical therapy), as appropriate.

Assessments are a key component of the Patient Driven Payment Model (PDPM) used by Medicare for Skilled Nursing Facility reimbursement. The Minimum Data Set, Version 3 (MDS 3.0) Resident Assessment Instrument is used to group patients into a payment category. The MDS 3.0 includes diagnosis, therapeutic services such as physical therapy, data about the patient’s level of functioning and more. This means that health record documentation is crucial to the PDPM documentation and, therefore, reimbursement. For more on the PDPM, refer to chapter 15. Revenue Management and Reimbursement.

Some of the data elements collected by the MDS 3.0 are used for the three assessments required by the PDPM. These assessments are the 5-Day Assessment (mandatory), Interim Payment Assessment (optional), and the Discharge Assessment (mandatory). The 5-Day Assessment and the Discharge Assessment will be performed on all Medicare SNF patients. The Interim Payment Assessment is performed when there is a significant change in the patient’s situation.

The physician’s role in a long-term care facility is not as visible as it is in other care settings. The physician develops a plan of treatment that ­includes the medications and treatments to be ­given to the resident. The physician visits the resident in the healthcare organizations on a 30- or 60-day schedule unless the resident’s condition requires more frequent visits. At each visit, the physician reviews the plan of care and physician orders and makes changes as necessary. Between visits, the physician is contacted when nursing personnel identify changes in the resident’s condition.

The following list identifies the most common components of long-term care records:

· Registration forms, including resident identification data

· Personal property list, including furniture and electronics

· History and physical and hospital records

· Advance directives, bill of rights, and other legal records

· Clinical assessments

· RAI and care plan

· Physician orders

· Physician’s progress notes and consultations

· Nursing notes

· Rehabilitation therapy notes (physical, occupational, and speech therapy)

· Social services, nutritional services, and activities documentation

· Medication and records of monitors, including administration of restraints

· Laboratory, radiology, and special reports

· Discharge or transfer documentation

When paper-based records are found in a long-term setting, a process called record thinning may occur at intervals during the patient’s stay. Records of patients whose stay extends to months or years become cumbersome to handle. Selected material may be removed and filed elsewhere according to the healthcare organization’s guidelines. Any material removed must remain accessible when needed for patient care and service evaluation.

Rehabilitation

The focus of services in physical medicine and rehabilitation settings is increasing a patient’s ability to function independently within the parameters of the individual’s illness or disability. The documentation requirements for rehabilitation facilities vary based on the type of rehabilitation services provided.

Inpatient rehabilitation hospitals and units within hospitals are reimbursed by Medicare ­under a prospective payment system. A Patient Driven Payment Model is completed on Medicare patients shortly after admission and upon discharge. Based on the patient’s condition, services, diagnosis, and medical condition, a payment level is determined for the inpatient rehabilitation stay. Comprehensive outpatient rehabilitation facilities have separate Medicare guidelines. For more information on the PAI, refer to chapter 15, Revenue Management and Reimbursement.

Many rehabilitation facilities are accredited through the Commission on Accreditation of Rehabilitation Facilities (CARF), although the Joint Commission or American Osteopathic Association (AOA) also can be chosen. CARF requires a facility to maintain a single case record for any patient it admits. The documentation standard for the health record includes the following requirements:

· Patient identification data

· Pertinent history, including functional history

· Diagnosis of disability and functional diagnosis

· Rehabilitation problems, goals, and prognosis

· Reports of assessments and program plans

· Reports from referring sources and service referrals

· Reports from outside consultations and laboratory, radiology, orthotic, and prosthetic services

· Designation of a manager for the patient’s program

· Evidence of the patient’s or family’s participation in decision-making

· Evaluation reports from each service

· Reports of staff conferences

· Progress reports

· Correspondence related to the patient

· Release forms

· Discharge summary

· Follow-up reports (CARF 2016)

Behavioral Health

Behavioral health records contain much of the same content as a nonbehavioral health record such as discharge summary, H&P, or physician orders. Behavioral health records contain a treatment plan that often includes family and caregiver input and information as well as assessments geared toward the transition to outpatient, nonacute treatment. CMS requires that the social workers assigned to a patient assess and document the family or home environment and community services that are compatible with the patient’s needs. The behavioral health record also contains a psychiatric evaluation that is performed by a healthcare provider appropriately trained to do such an evaluation and that evaluation consists of a patient history, current mental status, and cognitive function.

Home Health

Home health records contain documentation reflecting care and treatment provided to patients in the home setting. Home care itself takes many forms from very basic assistance that allows a patient to remain independent and live in his or her home, to short-term rehabilitation care, or comprehensive management of a chronic illness. The care provided in the home setting as well as the skill level of the healthcare professional providing the care is individualized based upon the needs of the patient.

The documentation that reflects the care and treatment in the home setting must be accurate and complete to ensure appropriate and quality care is provided to the patient, resulting in better patient outcomes. Quality home care documentation also drives appropriate coding, claims, and reimbursement for the treatment and care provided to the patient. Typically, the home health documentation itself includes an individualized treatment plan, general health assessment, problem list, treatment goals, interventions and outcomes, and communications with other healthcare providers.

Federal and State Initiatives on Documentation

As healthcare costs have steadily and, in many cases, dramatically increased over the years, the government, on state and federal levels, has focused its attention on alternative reimbursement and payment models. It has developed initiatives for the healthcare sector to follow with the goals of improving the quality of care provided and increasing efficiencies with an increased value of the care provided to patients. The alternative reimbursement and payment models, called pay-for-performance or value-based care, prioritize quality and efficiency rather than quantity. Healthcare providers such as hospitals and physicians are financially incentivized to put measures into place to continuously improve the quality and efficiency of the care they provide, resulting in better patient outcomes. Pay-for-performance programs have performance measures that healthcare providers must meet or exceed to receive financial payment. For example, Medicare may hold a percentage of reimbursement until the healthcare provider meets the quality standards. Clinical documentation plays a key role in demonstrating if a healthcare provider is meeting or exceeding these performance measures.

There are several federal and state initiatives related to quality and content of health record documentation. Two initiatives, however, are more commonly found across the entire healthcare continuum. These initiatives are the Medicare Access and CHIP Reauthorization Act (MACRA) and core measures. Both MACRA and core measures emphasize the quality and efficiency aspects of the treatment physicians and other healthcare providers provide to patients more than the quantity of the treatment provided.

MACRA was signed into law in 2015 by then President Barack Obama. Like other pay-for-­performance initiatives, MACRA financially rewards healthcare providers for treatment. By meeting specific measures, the documentation generated by the treatment of Medicare beneficiaries demonstrates (or not) that the treatment provided was high-quality, efficient, and a good value for the patient. Moreover, greater emphasis is being placed on the patient outcomes over time. Healthcare providers are and will continue to be evaluated for patient outcomes and general management of specific conditions within the Medicare patient population.

Core measures are national treatment standards for specific healthcare conditions that were developed and continue to be developed and updated based on scientific clinical findings. Core measures have been proven to improve overall patient outcomes during treatment of these conditions. The goal of the core measures is to reduce patient adverse events and complications. The documentation of the treatment must reflect adherence to the core measures. Healthcare providers typically report core measures monthly or quarterly to the Joint Commission, CMS, or other agency. The documentation of the adherence to and subsequent reporting of the core measures demonstrates how frequently the healthcare provider follows the standards related to specific healthcare conditions. This reporting reflects, in part, the level of quality treatment and care the healthcare provider provides to his or her patient population.

Health Information Media

Over the years, healthcare documentation media has transformed from a paper-based health record that sat on a shelf to an EHR that can be shared. Many of the same rules, standards, and quality measures that held true for the paper-based health record hold true now for the EHR. Healthcare documentation integrity is paramount regardless of its form. In many respects, the rules, standards, and quality measures and indicators are available through EHR software enhancements that can leverage technology against what was once a manual process. Leveraging EHR features and technical capabilities in conjunction with strong and concise policies and procedures can ensure the integrity and accuracy of health record documentation (AHIMA 2013).

Paper Health Record Documentation

Some healthcare organizations still utilize the paper-based health records. The paper-based health record can take the source-orientated health record format in which the documentation is organized by source or originating department. For instance, all nursing notes are together, and all the physician progress notes are grouped together. With each source, the health record documentation is placed in reverse chronological order, where the most current or recent documentation is first. Reverse chronological order is kept while the patient is being treated. Many times post patient discharge, the health record is kept in its source orientation, but the documentation in each source section is rearranged and placed in chronological order. Other times, the health record post patient discharge is kept in reverse chronological order; this is called universal chart order.

In an integrated health record, the documentation is placed in chronological order regardless of source. This means that the lab results, nurses’ notes, physician orders, and physician progress notes are placed in the order in which they occurred. The order of the health record is determined by when the documentation was entered into the health record, when the service or treatment was rendered, or when a test result was processed.

The subjective, objective, assessment, plan (SOAP) method is used to construct physician progress notes. Physicians use the acronym SOAP to remember what elements of documentation must be included in a progress note. The SOAP methodology came from the problem-oriented health record developed by Lawrence Reed in the 1970s, which defines and documents clinical problems individually (AAPC 2015). The problem-oriented health record consists of a problem list, the history and physical examination and ­initial lab findings (the database), the initial plan (tests, procedures), and progress notes. The HIM professional must be able to read and understand the documentation structure to locate information needed for coding, audits, and other usages.

As EHR technologies have advanced, the paper-based health record is considered antiquated by many. There are numerous shortcomings to the paper-based health record, notably the inability to share needed health information with multiple healthcare providers at one time (access and availability), as well as the lack of controls that can be placed in and around the paper-based health record in terms of data security. See chapter 10, Data Security, for more detail on data security.

Electronic Health Record Documentation

Computer-based health record documentation via EHRs has been in existence for 50 years. Over time, as EHR systems became more sophisticated, the way healthcare providers document the treatment and services they render to the patient also dramatically changed. Before EHR adoption, healthcare providers would carry paper-based health records into the patient’s room to reference as they discussed and rendered treatment to the patient. The healthcare provider did not document what occurred until after seeing the patient. Today, EHRs allow point-of-care documentation to take place—the healthcare provider can log into the EHR in the exam or treatment room and document in the patient’s health record during the exam or treatment. This change in the way healthcare documentation is captured has impacted treatment workflow in some of the most meaningful ways. See chapter 11, Health Information Systems, for additional information on the EHR.

Web-Based Document Imaging

Document imaging is the process by which paper-based documentation is captured, digitized, stored, and made available for retrieval by the end user (AIIM 2019). Although many healthcare provider organizations have an EHR, there remains a good deal of paper-based documentation that must be integrated and included in the patient’s EHR. Current EHR systems contain documentation-imaging and document-management technologies that provide for the capture, digitization, integration, storage, and retrieval of paper-based health record documentation.

Healthcare Providers in Documentation

Authenticated, accurate, legible, complete, and timely documentation is paramount to patient safety, quality of care provided to patients, and appropriate reimbursement. Healthcare providers have an obligation to document appropriately, reflecting a true picture of the treatment and services rendered to the patient. Not only does the health record documentation itself need to be of the highest quality, the health record also must be organized and available to the healthcare providers who need it to care for the patient. Physicians, nurses, allied health professionals, and HIM professionals all play vital roles in meeting the documentation standards from a healthcare organization’s policy and procedural perspective and meeting regulatory requirements applicable to health record documentation.

Physicians

Patients place a significant level of trust in their physicians. Patients rely on their physicians to make sound medical decisions about them and document them accordingly. Payers and the government also trust physicians to document appropriately in the health record so quality care can be rendered and appropriate reimbursement issued by the payer. The information a physician documents in the health record impacts the patient first and foremost. All physicians caring for the patient and payers connected to the physicians need to coordinate their care and documentation. See chapter 16, Fraud and Abuse Compliance, for information on regulatory laws that directly and indirectly govern physician documentation. Those laws fall into the general category of fraud and abuse laws, but the False Claims Act and Anti-Kickback Statute have significant documentation compliance ­jurisdiction for physicians.

Nurses

Nurses play an important role in the day-to-day caregiving of a patient, and they are an important member of the patient care team. As with physicians, the way a nurse documents in the health record is based on the environment. Inpatient health record documentation looks slightly different from documentation in the operating room or in a long-term care facility. The elements or components that the nurse captures in the documentation also varies depending upon licensing and regulatory requirements, as well as the healthcare organization’s internal policies and procedures. However, the same rules apply to nursing documentation as to physician documentation. Legible, complete, and timely entries are required. In addition, though the documentation of a physician is both subjective and objective, nursing documentation should only be objective in nature. In terms of the legal environment, nursing documentation standards tend to be more restrictive than physician documentation standards because physicians, not nurses, diagnose patients.

Allied Health Professionals

Some allied health professionals work more independently than others when providing treatment and services to the patient. Many follow a treatment plan developed by the patient’s physician. In this case, the allied health professional documents the treatment and the patient’s response to the treatment.

The allied health professional usually falls into one of two categories of practice—technician (­assistant) and therapist or technologist. In both categories of practice, allied health professionals may have to meet certification and licensing requirements in addition to the standard documentation practices of an organization. Chapter 2, Healthcare Delivery Systems, discusses allied health professionals in more detail.

HIM and Documentation

While HIM professionals do not document in the health record, the documentation in the health record is important to them for coding, claim generation, data quality monitoring, disclosure of health information, and such. Complete, accurate, and available health record information is essential for quality care and patient safety. Other healthcare providers, the government, and payers expect the health record documentation to accurately reflect the treatment and services provided to the patient. This level of documentation is needed to ensure the patient receives the best quality healthcare available and that the appropriate reimbursement is received for the treatment and services provided. HIM professionals are often in charge of ensuring that physician documentation is complete and accurate and that the health record documentation is organized and readily accessible when needed for patient care. AHIMA defines information governance as “an organization-wide framework for managing information throughout its life cycle and supporting the organization’s strategy, operations, regulatory, legal, risk, and environmental requirements” (AHIMA 2014, 70). The governance or management of health record information is a fundamental component of the overall information governance model. Information governance applies to many categories of data, including health record information. HIM professionals play vital and different roles in the overall governance of health record information. For information on data governance, see chapter 6, Data Management.

HIM professionals manage many aspects of the health record and its content. This includes the ­following 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 the health record documentation for appropriate reimbursement

· Controlling the access and disclosure of the health record and its content across a healthcare organization

Within an EHR environment, HIM professionals are viewed as the experts to develop workflows and infrastructure around the EHR. As EHR technology proliferates, traditional HIM job roles continue to be more information technology (IT) focused. Continuing to learn and expand knowledge within the computer technology field and continuing to learn the many ways IT can be leveraged to improve the EHR infrastructure to support information governance is paramount. HIM professionals and the roles they play will continue to evolve—as they will be involved in clinical documentation integrity (CDI), forms design, screen design, data quality, and so much more.

HIM Roles

Health information management roles within healthcare have drastically changed over the past 10 to 15 years as the EHR has evolved. As more and more healthcare entities have transitioned from paper-based records to electronic-based records, traditional HIM roles have been ­impacted. HIM professionals have readily adapted to this impact and have taken more of a technical focus in response. An important role for HIM professionals is the clinical documentation integrity coordinator. The clinical documentation coordinator works with physicians to ensure the documentation is completed and contains enough information to assign diagnosis and procedure codes. For example, the documentation should identify whether the right or left radius was fractured.

Another role related to documentation is the analyst role. The analyst is responsible for ensuring the presence of key documents as defined by the healthcare organization and that the health record entries are authenticated and dated.

Real-World Case 4.1

The hospital clinical documentation improvement (CDI) specialist reports to you, the HIM manager of Anywhere hospital, that the hospital has been receiving reimbursement penalties. The physician documentation is not appropriately identifying specific conditions that CMS has identified as hospital-acquired conditions (HACs). In most cases, these conditions are present in patients before they are admitted. However, physicians are documenting these conditions later in the patients’ stays, making it appear that the patients have ­acquired these conditions from the hospital. The hospital is being financially penalized because these conditions are considered to be preventable if the hospital follows national treatment standards and guidelines.

Anywhere hospital has a robust EHR. Many ­documentation improvement initiatives have been leveraged by the technological capabilities of the EHR. As the HIM manager, you wonder if something could be done from a technology standpoint that could assist physicians with identifying, upon admission, those conditions that are causing the reimbursement issue, and appropriately documenting the conditions. Physicians appropriately capturing and documenting these conditions would demonstrate that the hospital is following the national treatment standards and guidelines and the patients are not acquiring these conditions in the hospital.

You assemble a multidisciplinary team consisting of physicians, revenue cycle representatives, HIM, and information systems representation.