Health Information Chapter 3

One of primary purposes of the health record:
It is a tool for documenting patient care
What does a health record represent?
A record represents the main communication mechanism used by healthcare providers in the delivery of patient treatment.
Without the health record, providers would be unable to do what?
Provide safe and effective care
What is the term used most widely by federal government and other entities for computer based health records?
Electronic health records (EHR)
What does the electronic health record (EHR) refer to?
It refers to a health record available electronically, allowing communication across providers and permitting real-time decision making. It also allows for efficient reporting mechanisms.
Other terms that reflect the evolution of the concept of the EHR include:
Electronic Medical Record (EMR)
Computer-based patient record (CPR)
We will write a custom essay sample on
Any topic specifically for you
For only $13.90/page
Order Now
Electronic health record (EHR) defn:
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization
Computer-based patient record (CPR):
An electronic patient record housed in a system designed to provide users with access to complete and accurate data, practitioner alerts and reminders, clinical decision support systems, and links to medical knowledge; See electronic health record
Electronic medical record (EMR):
An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within a single healthcare organization
Electronic medication administration record (EMAR):
A system designed to prevent medication errors by checking a patient’s medication information against his or her barcoded wristband
Electronic prescribing (e-Rx):
When a prescription is written from the personal digital assistant and an electronic fax or when an actual electronic data interchange transaction is generated that transmits the prescription directly to the retail pharmacy’s information system
Hybrid record
√When a facility is transitioning from paper to electronic systems and uses components of both, the record is referred to as a hybrid record
√A health record that includes both paper and electronic elements.
Example of the steps an organization takes in the transition from paper-based health record formats to computer-based systems.
√Example of the steps an organization takes in the transition from paper-based health record formats to computer-based systems.
√The conditions of admission, consents and authorizations, physician progress notes, anesthesia and sedation reports, intra-operative records, emergency and ambulatory surgery records, and patient discharge instructions and referrals are paper documents.
√Emergency visit documents are gathered six hours after patient release and are scanned into the electronic system.
√All dictated physician reports (history and physicals, operative reports, consultations, and discharge summaries) are immediately available in the electronic record after transcription.
AZ Mayo case study example of steps an organization takes in the transition from paper-based health record formats to computer-based systems cont.
√Paper versions of the reports are scanned into the imaging system upon patient discharge for purposes of obtaining physicians’ electronic signatures.
√All other documentation, including that done by nurses, therapists, and other health professionals, and diagnostic or therapeutic testing, including imaging, are recorded and reported electronically.
√Subsequent to its opening, the facility implemented a computerized physician order-entry (CPOE) component and now manages the orders and an automated prescription pad electronically.
AZ Mayo case study uses: Discharge record analysis
√Reviewing the record upon patient discharge for missing elements
√Is done by health information personnel using a computer for the case study example mentioned here
√The system filters documents so that only those needing review are accessed by the staff completing the deficiency analysis
√Electronic signatures are used and physicians access the system at any of the Arizona Mayo sites
Once the discharge analysis is completed:
E-mail reminders to physicians on record deficiencies are generated automatically upon completion of analysis.
AZ Mayo case study: Parts of the record that are generated on paper:
√Are stored for a very short period of time after scanning
√All release of information and other processes, including coding, use the computer-based record
Mayo clinic’s outpatient clinic:
√This practice uses the same electronic record as the hospital
√Computers are in each exam room and in stations outside the rooms
√Info such as current medications and allergies can be entered directly here
√Notes for all patient visits at the clinic and from the two primary care practice sites located elsewhere in the metro are dictated immediately after each visit
√Similar to hospital-dictated reports, they are transcribed and made immediately available as part of the electronic record
Paper documents in the outpatient setting include:
Consents, insurance cards, and miscellaneous specialty-specific documentation.
All paper documents are picked up hourly by health information personnel, and:
√Scanned and indexed into the imaging system, and reviewed for quality
Scanned records are available in what amount of time?
The scanned material is available in the electronic record within two hours of the pickup time
Content of the health record: Information in the health record is provided directly by who?
The healthcare professionals who participate in the patient’s care
Content of the health record: What is information in a health record used for?
√Planning and managing diagnostic, therapeutic, and nursing services
√Evaluating the adequacy and appropriateness of care
√Substantiating reimbursement claims
√Protecting the legal interests of the patient, the healthcare provider, and the healthcare organization
√Additionally, the health record is a tool used by patient’s caregivers to communicate with each other
How else is the information in a health record used?
√Info collected from health records is used in research, public health, and educational and organizational activities such as medical research, professional training, performance improvement, risk management, and strategic planning
What are the two types of data contained in a health record?
1. Clinical
2. Administrative
Clinical data in part of a health record is:
Clinical data documents the patient’s medical condition, diagnosis, and procedures performed as well as the healthcare treatment provided.
Administrative data in part of a health record is:
Administrative data include demographic and financial information as well as various consents and authorizations related to the provision of care and the handling of confidential patient information.
The content of the health record varies, depending on what?
√The healthcare setting and the provider’s medical specialty
√Record content is determined primarily by practice needs and pertinent standards
What are standards related to health record content?
Standards are statements of expected behavior or reference points against which structures, processes, or outcomes can be measured.
Standards for documentation can be found in the following four main sources:
√Facility-specific standards
√Licensure requirements
√Government reimbursement programs
√Accreditation standards: Accreditation is the end result of an intensive external review process that indicates a facility has voluntarily met the standards of the independent accrediting organization (such as the Joint Commission).
As a main source making up the Standards for documentation, Facility-specific standards are found where? What do they govern?
√Facility-specific Standards might be found in facility policies and procedures and, when a facility has an organized medical staff, in the medical staff bylaws, rules, and regulations.
√Facility-specific guidelines govern the practice of physicians and others within a specific organization.
A main source making up the Standards for documentation, describe the need for Licensure requirements:
Before they can provide services, most healthcare organizations must be licensed by government entities such as the state or county in which they are located and must maintain a license as long as care is provided.
A main source making up the Standards for documentation, when are Government reimbursement program standards applied:
√Standards are applied to facilities that choose to participate in federal government reimbursement programs such as Medicare and Medicaid.
√These standards are titled Conditions of Participation or Conditions for Coverage.
√Facilities are said to be certified if the standards are met.
Facilities are said to be certified if what?
If the standards are met
In the government reimbursement program, what are the Conditions of Participation or Conditions for Coverage?
√Conditions of Participation:The administrative and operational guidelines and regulations under which facilities are allowed to take part in the Medicare and Medicaid programs; published by the Centers for Medicare and Medicaid Services, a federal agency under the Department of Health and Human Services; also called

√Conditions for Coverage Confidentiality: A legal and ethical concept that establishes the healthcare provider’s responsibility for protecting health records and other personal and private information from unauthorized use or disclosure

A main source making up the Standards for documentation, describe the need for Accreditation standards:
Accreditation is the end result of an intensive external review process that indicates a facility has voluntarily met the standards of the independent accrediting organization (such as the Joint Commission)
The standards of the four main sources or groups does what?
√Address content
√Often also outline time limits for completion of particular portions of the health record
√Healthcare data sets also help determine elements of record content
How do healthcare data sets determine elements of record content?
As an example, the Uniform Ambulatory Care Data Set outlines what data should be documented in facilities where ambulatory care is delivered
Basic Acute Care Documentation: basic content of health records maintained by acute care hospitals
√The basic components will be found in a record whether the record is paper-based, hybrid, or computer-based. √However, the actual location of data elements, whether found on a paper form or across computer screens, will vary.
√A number of groups provide standards for acute care hospital documentation from all four sources noted above
All include record content requirements:
√Federal government Conditions of Participation for Hospitals, for critical access hospitals (facilities in rural settings meeting special criteria), and for transplant hospitals all include record content requirements.
Which programs provide hospitals with options for voluntary external review?
√Accreditation standards from the Joint Commission, the Healthcare Facilities Accreditation Program of the American Osteopathic Association (AOA), or the DNV’s (Det Norske Veritas) NIAHO standards provide hospitals with options for voluntary external review.
American Osteopathic Association (AOA):
The professional association of osteopathic physicians, surgeons, and graduates of approved colleges of osteopathic medicine that inspects and accredits osteopathic colleges and hospitals
As a basic component of the acute care health record: What is the function of the Registration record?
Documents demographic information about the patient
As a basic component of the acute care health record: What is the function of the Medical History?
Documents the patient’s current and past health status
As a basic component of the acute care health record: What is the function of the Physical examination?
Contains the provider’s findings based on an examination of the patient
As a basic component of the acute care health record: What is the function of Clinical Observations?
Provide a chronological summary of the patient’s illness and treatment as documented by physicians, nurses, and allied health professionals
As a basic component of the acute care health record: What is the function of the Physician’s orders?
Document the physician’s instructions to other parties involved in providing the patient’s care, including orders for medications and diagnostic and therapeutic procedures
As a basic component of the acute care health record: What is the function of the Reports of diagnostic and therapeutic procedures?
Describe the procedures performed and give the names of clinicians and other providers; include the findings of x-rays, mammograms, ultrasounds, scans, laboratory tests, and other diagnostic procedures
As a basic component of the acute care health record: What is the function of the consultation reports?
Document opinions about a patient’s condition furnished by providers other than the attending physician
As a basic component of the acute care health record: What is the function of the Discharge Summary?
Concisely summarizes the patient’s stay in a hospital
As a basic component of the acute care health record: What is the function of the Patient instructions?
Document the instructions for follow-up care that the provider gives to the patient or the patient’s caregiver
As a basic component of the acute care health record: What is the function of the Consents, authorizations, and acknowledgements?
Document the patient’s agreement to undergo treatment or services, permission to release confidential information, or recognition that information has been received
Who gives the hospital some preliminary info about a patient before they are admitted to the hospital?
The patient’s attending or primary physician usually gives the hospital some preliminary information about the patient before he or she is admitted to the hospital.
What does the information given to the hospital before a patient is admitted include?
√Such information includes an admitting or working diagnosis, also called a provisional diagnosis
An admitting or working diagnosis, is also called:
A provisional diagnosis
What does the diagnosis identify?
√The diagnosis identifies the condition or illness for which the patient needs medical care
Where is the admitting or working diagnosis recorded?
This information is recorded on an admission or registration record, also referred to as a face sheet in paper-based systems
What is an admission or registration record also called?
A face sheet (in paper-based systems)
What does the admission record also include?
Demographic and financial data about the patient.
What types of clinical data are documented in the health record during the patient’s hospital stay?
√Patient’s medical history and pertinent family history
√Report of the patient’s initial physical examination
√Attending physician’s diagnostic and therapeutic orders
√Clinical observations of the providers who care for the patient
√Reports and results of every diagnostic and therapeutic procedure √Reports of consulting physicians
√Patient’s discharge summary
√Final instructions to the patient upon discharge
Definition of medical history:
A record of the information provided by a patient to his or her physician to explain the patient’s chief complaint, present and past illnesses, and personal and family medical problems; includes a description of the physician’s review of systems
A complete medical history documents primarily what?
A complete medical history documents the patient’s current complaints and symptoms, and lists his or her past medical, personal and family history.
Who has the responsibility of the medical history in acute care?
In acute care, the medical history is usually the responsibility of the attending physician.
Medical histories obtained by specialists such as gynecologists and cardiologists concentrate on what?
On the organ systems involved in the patient’s current illness.
Information usually included in a complete medical history, or components of the history include:
√Chief complaint
√Present illness
√Past medical history
√Social and personal history
√Family medical history
√Review of systems
Complaints and symptoms of the component Chief Complaint include:
Nature and duration of the symptoms that caused the patient to seek medical attention as stated in his or her own words
Complaints and symptoms of the component Present Illness include:
Detailed chronological description of the development of the patient’s illness, from the appearance of the first symptom to the present situation
Complaints and symptoms of the component Past medical history include:
Summary of childhood and adult illnesses and conditions, such as infectious diseases, pregnancies, allergies and drug sensitivities, accidents, operations, hospitalizations, and current medications
Complaints and symptoms of the component Social and personal history include:
Marital status; dietary, sleep, and exercise patterns; use of coffee, tobacco, alcohol, and other drugs; occupation; home environment; daily routine; and so on
Complaints and symptoms of the component Family Medical history include:
Diseases among relatives in which heredity or contact might play a role, such as allergies, cancer, and infectious, psychiatric, metabolic, endocrine, cardiovascular, and renal diseases; health status or cause of and age at death for immediate relatives
Complaints and symptoms of the component Review of Systems include:
Systemic inventory designed to uncover current or past subjective symptoms that includes the following types of data:
•General: Usual weight, recent weight changes, fever, weakness, fatigue

•Skin: Rashes, eruptions, dryness, cyanosis, jaundice; changes in skin, hair, or nails

•Head: Headache (duration, severity, character, location)

•Eyes: Glasses or contact lenses, last eye examination, glaucoma, cataracts, eyestrain, pain, diplopia, redness, lacrimation, inflammation, blurring

•Ears: Hearing, discharge, tinnitus, dizziness, pain

•Nose: Head colds, epistaxis, discharges, obstruction, postnasal drip, sinus pain

•Mouth and throat: Condition of teeth and gums, last dental examination, soreness, redness, hoarseness, difficulty in swallowing

•Respiratory system: Chest pain, wheezing, cough, dyspnea, sputum (color and quantity), hemoptysis, asthma, bronchitis, emphysema, pneumonia, tuberculosis, pleurisy, last chest x-ray

•Neurological system: Fainting, blackouts, seizures, paralysis, tingling, tremors, memory loss

•Musculoskeletal system: Joint pain or stiffness, arthritis, gout, backache, muscle pain, cramps, swelling, redness, limitation in motor activity

•Cardiovascular system: Chest pain, rheumatic fever, tachycardia, palpitation, high blood pressure, edema, vertigo, faintness, varicose veins, thrombophlebitis

•Gastrointestinal system: Appetite, thirst, nausea, vomiting, hematemesis, rectal bleeding, change in bowel habits, diarrhea, constipation, indigestion, food intolerance, flatus, hemorrhoids, jaundice

•Urinary system: Frequent or painful urination, nocturia, pyuria, hematuria, incontinence, urinary infections

•Genitoreproductive system: Male—venereal disease, sores, discharge from penis, hernias, testicular pain, or masses; female—age at menarche, frequency and duration of menstruation, dysmenorrhea, menorrhagia, symptoms of menopause, contraception, pregnancies, deliveries, abortions, last Pap smear

•Endocrine system: Thyroid disease; heat or cold intolerance; excessive sweating, thirst, hunger, or urination

•Hematologic system: Anemia, easy bruising or bleeding, past transfusions

•Psychiatric disorders: Insomnia, headache, nightmares, personality disorders, anxiety disorders, mood disorders

Diagnostic and therapeutic orders: Physician’s orders
Are the instructions the physician gives to the other healthcare professionals who actually perform diagnostic tests and treatments, administer medications, and provide specific services to a particular patient.
Admission and discharge orders should be found for every patient unless:
The patient leaves the facility against medical advice (AMA), but other orders will vary from patient to patient.
All orders must be the following:
√Legible and include the date and the physician’s signature.
√In electronic systems, signatures are attached via an authentication process
Standing orders
Are orders the medical staff or an individual physician have established as routine care for a specific diagnosis or procedure.
Standing orders are commonly used:
In hospitals, ambulatory surgery facilities, and long-term care facilities
How are standing orders presented?
Usually, standing orders are preprinted on a single sheet of paper or available via a standard computer screen.
Like other physician’s orders, standing orders also need what?
Like other physician’s orders, they must be signed and dated.
How physician’s may communicate orders:
√Verbally or via the telephone when the hospital’s medical staff rules allow.
√How the orders are to be signed as well as the time period allowed for authentication also may be specified.
What will specify which practitioners are allowed to accept and execute verbal and phone orders?
√State law and medical staff rules specify which practitioners are allowed to accept and execute verbal and telephone orders.
Clinical observations
√In acute care hospitals, the documentation of clinical observations is usually provided in progress notes.
√The purpose of documenting the clinical observations of physicians, nurses, and other caregivers is to 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 the facility.
√In addition, they document the appropriateness and coordination of the services provided. The patient’s condition determines the frequency of the notes.
In acute care hospitals, how is the documentation of clinical observations provided?
Progress notes
What is the purpose of documenting clinical observations of physicians and other health care providers?
To create a chronological report of the patient’s condition and response to treatment during his or her hospital stay.
What do progress notes serve to do?
Progress notes serve to justify further acute care treatment in the facility. In addition, they document the appropriateness and coordination of the services provided.
What determines the frequency of progress notes?
The patient’s condition determines the frequency of the notes.
Physician Notes; special type progress note
√Begins with history and physical exam
√Progress notes made by the hospital’s medical staff and healthcare providers, all that have been authorized to enter progress notes.
√These can be done in sections based on discipline, or may be done chronologically.
√Guidelines for frequency are found in the Rules and Regulations, as are the rules guiding who is authorized to enter progress notes.
What specifies which healthcare providers are allowed to enter progress notes in the health record?
√The rules and regulations of the hospital’s medical staff specify which healthcare providers are allowed to enter progress notes in the health record.
Who is typically authorized to enter progress notes?
√Typically, the patient’s attending physician, consulting physicians who have medical staff privileges, house medical staff, nurses, nutritionists, social workers, and clinical therapists are authorized to enter progress notes.
How might a health record be laid out?
Depending on the 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. (Source-oriented and integrated health records are discussed later in this chapter.)
Where would the guidelines for frequency of notations be found?
√Guidelines for the frequency of notations may also be found in the Rules and Regulations.
Medical staff privileges
Permission granted to provide clinical services in a healthcare facility based on the credentials of the individual and limited to a specific scope of practice
________ types of notes are frequently found in a record.
Example of special types of notes found in a hospital health record:
1) Pre-anesthesiologist notes
2) A postanesthesia note
3) Pre-surgical evaluation
4) Post-surgical evaluation
Describe pre-anesthesologist special type notes found in a health record:
•Prior to the administration of anything 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 administration.
•Allergies and drug reactions would be noted here
Post-anesthesologist special type notes found in a health record
Describe the patient’s recovery from the anesthetic
Who must document major procedure “special type” notes found in a hospital health record?
The surgeon responsible for a major procedure must document both pre- and postsurgical patient evaluations.
What should be added to the hospital health record when a patient dies in hospital care? And who adds this?
√The attending physician should add a summary statement to the patient’s health record to document the circumstances surrounding the patient’s death.
In what forms can a summary statement to document circumstances surround a patient’s death on a patient’s health record come?
√The statement can take the form of a final progress note or a separate report.
What should the summary statement about a patient’s death indicate?
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
Nursing and Allied Health Notes and Assessments
Nurses and allied health professionals (for example, occupational, physical, respiratory, and speech therapists; dieticians; and social workers) may begin their care with assessments focused on understanding the patient’s condition from the perspective of their specialized body of knowledge
What may often follow a nursing and allied health notes assessment?
Often a care plan may follow the assessment.
Care Plan
The specific goals in the treatment of an individual patient, amended as the patient’s condition requires, and the assessment of the outcomes of care; serves as the primary source for ongoing documentation of the resident’s care, condition, and needs
What is a care plan a summary of?
A summary of the patient’s problems from the nurse or other professional’s perspective with a detailed plan for interventions.
What other notes and documenting are nurses responsible for?
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.
Nursing notes regarding patient deaths in the hospital:
If a patient should die while hospitalized, nursing notes regarding the circumstances leading to and of death are important.
Nurses also maintain chronological records of what?
√The patient’s vital signs
Including: blood pressure, heart rate, respiration rate, and temperature
√Separate logs that show what medications were ordered and when they were administered
What other chronological monitors may be ordered based on the patient’s diagnosis?
Other chronological monitors such as patient input and output records also may be ordered depending on the patient’s diagnosis.
What are referred to as flow records? What do they show?
Chronological monitors 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.
After an initial assessment, documentation by other allied health professionals varies by what?
How will each facility define appropriate content and frequency of recording?
Using specific regulations and standards in addition to the profession’s practice guidelines.
Example of using specific regulations and standards in addition to the profession’s practice guidelines for documentation:
Respiratory therapy treatments may be documented via samples of graphic monitors with interpretations and social work interventions may appear as dictated reports.
Reports of Diagnostic and Therapeutic Procedures become part of what?
The patient’s health record.
Diagnostic procedures include the following:
•Lab tests performed on blood, urine, and other samples from the patient
•Pathological examinations of tissue samples and tissues or organs removed during surgical procedures
•Radiological scans and images of various parts of the patient’s body and specific organs
•Monitors and tracings of body functions
The results of most laboratory procedures are:
Generated electronically by automated testing equipment.
In contrast to results of most lab procedures that are generated electronically, the results of monitors, radiology and path procedures require what?
The results of monitors, radiology, and pathology procedures require: interpretation by specially trained physicians such as cardiologists, radiologists, and pathologists.
What do physicians do with these interpreted (vs. automated) test results?
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.
Procedure and Surgical Documentation: Any major diagnostic procedure or surgical event requires what?
Special documentation
Special documentation for major diagnostic or surgical event includes what?
•Preoperative notes (made by the anesthesiologist and surgeon prior to the procedure)
•Nurses report preoperative patient preparations
•Entire procedure itself is recorded, along with an:
•Anesthesia record
•An operative report, and a
•Postanesthesia (or recovery room
•When tissue is removed for evaluation, a pathology report also must be present.
Patient Consent Documentation: What needs to happen before a patient consents to a procedure?
The patient must consent to a procedure after:
•An explanation and
•An opportunity to ask questions
What are often designed to provide evidence of patient consent to a procedure?
Special documents or screens are designed to provide evidence of consent, including the appropriate signature.
The need to obtain the patient’s consent before medical and surgical procedures is based on the legal concept of what?
Definition of battery as a legal concept as it relates to medical and surgical procedures:
Battery is the unlawful touching of a person without his or her implied or expressed consent.
What is implied consent when related to consent of a patient in a medical or surgical procedure?
•Implied consent is assumed when a patient voluntarily submits to treatment.
•The rationale behind this assumption is that one can reasonably assume that the patient understands the nature of the treatment or would not submit to it.
Expressed consent
•Expressed consent is a consent that is either spoken or written.
•Although courts recognize both spoken and written consent, spoken consent is more difficult to prove.
It is primarily the physician’s responsibility to make sure that the patient understands what before the procedure is performed?
•The nature of a medical procedure
•Alternative treatments
•The procedure’s risks
•The procedure’s complications
•The benefits of the procedure
What guides usually list which types of services and procedures always require written consent from the patient?
Medical staff rules or hospital policies usually list which types of services and procedures always require written consent from the patient.
Generally, procedures that require written consent involve the use of:
Generally, procedures that involve:
•The use of anesthetics
•The administration of experimental drugs
•The surgical manipulation of organs and tissues •Significant risk of complications
Some states now require what for certain tests, such as HIV for example?
Some states have passed laws that require written consent forms for certain types of testing procedures
Written consents
•Should be witnessed by at least one individual •Should be obtained prior to the service or procedure
•Original or scanned copies of consents should always become part of the patient’s health record
The anesthesia report notes:
•Any preoperative medication and response to it
•The anesthesia administered with dose and method of administration
•The duration of administration
•The patient’s vital signs while under anesthesia, •Any additional products given to the patient during the procedure.
Who is responsible for the anesthesia report information?
The anesthesiologist or nurse anesthetist is responsible for this documentation.
Procedure and Operative Reports: What is the Operative report? What does it describe?
•A formal document that describes the events surrounding a surgical procedure or operation and identifies the principal participants in the surgery.
•The operative report describes the surgical procedures performed on the patient.
Each operative report usually includes what information?
•Patient’s preoperative and postoperative diagnosis
•Descriptions of the procedures performed
•Descriptions of all normal and abnormal findings
•Description of the patient’s medical condition before, during, and after the operation
•Estimated blood loss
•Descriptions of any specimens removed
•Descriptions of any unique or unusual events during the course of the surgery
•Names of the surgeons and their assistants
•Date and duration of the surgery
Who writes or dictates the operative report? When is this done?
The operative report should be written or dictated by the surgeon immediately after surgery and become part of the health record.
What should be added when there is a delay in dictation or transcription of an operative report?
When there is a delay in dictation or transcription, a progress note describing the surgery should be entered into the patient’s record.
Should reports of other procedures or treatments be associated with surgery? Give an example:
They may or may not be associated with surgery. For example, administration of blood transfusions may occur prior to, during, or after surgery, but chemotherapy documentation is usually separate from that of other procedures.
What is a Recovery Room Report? When and by whom is it dictated?
•After a procedure, the patient is evaluated for a period of time in a special unit called a recovery room, this creates the recovery room report.
•This report is taken immediately after the procedure.
What does the recovery room report include?
The recovery room report includes:
•Postanesthesia note (if not found elsewhere), •Nurses’ notes regarding the patient’s condition and surgical site, vital signs, and intravenous fluids and other medical monitoring.
Why is monitoring in a recovery room important after a procedure?
Monitoring is important to make sure the patient sufficiently recovers from the anesthesia and is stable enough to be moved to another location.
Pathology Report
•A pathology report is dictated by a pathologist
•It’s dictated after examination of tissue received for evaluation
What does a pathology report include?
•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 report would follow
Surgical pathology report headings:
1. Specimen stated to be
2. Clinical diagnosis
3. Macroscopic
4. Microscopic
5. Diagnosis
What does the consultation report document?
The consultation report documents the clinical opinion of a physician other than the primary or attending physician.
Who requests the consultation report?
The consultation is requested by the primary or attending physician.
What is the consultation report based on?
The report is based on the consulting physician’s examination of the patient and a review of his or her health record.
How are consultation requests made? What information is provided? What happens next?
•Some organizations make consultation requests by telephone
•The consultant is provided with selected information from the patient’s record
•Next, the consultant then dictates his or her findings and returns them to the requesting physician.
•Other organizations use a consultation form •The first part of the form communicates the consultation request and provides the consultant with pertinent patient history
•The consultant then uses the second part to document and return his or her opinion to the requesting physician
What is the discharge summary?
The discharge summary is a concise account of the patient’s:
•Course of treatment
•Response to treatment, and
•Condition at the time the patient is discharged (officially released) from the hospital
What else does the discharge summary include:
The summary also includes instructions for follow-up care to be given to the patient or his or her caregiver at the time of discharge
Because the discharge summary provides an overview of the entire medical encounter, it:
•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
Who is responsible for the discharge summary, and who must sign it?
The discharge summary is the responsibility of, and must be signed by, the attending physician
When is a discharge note acceptable in place of a full discharge summary?
A discharge note in place of a full summary is often acceptable when:
•If the patient’s stay is not complicated
•If a patient’s stay lasts less than 48 hours
•If a patient’s stay involves an uncomplicated delivery or normal newborn
Name the section titles on a discharge summary report:
•Date of discharge
•Principal operation and procedure
•History of present illness
•Admitting diagnosis
•Hospital course
•Lab data at discharge
•Medications at discharge
•Final diagnosis
Patient Instructions and Transfer Records
It is vital that the patient be given clear, concise instructions upon discharge so that progress in recovery from hospitalization continues.
How are patient instructions ideally communicated?
•Ideally, patient instructions are communicated both verbally and in writing
•Many hospitals have designed documents for this purpose
The healthcare professional who delivers the instructions to the patient or caregiver should do what with the record? What should the person receiving the instructions do?
•They should sign the record to indicate that he or she has issued them
•The person receiving the instructions should sign to verify that he or she understands them.
•A copy of the written instructions then becomes part of the health record
What should happen when someone other than the patient assumes responsibility for the patient’s aftercare?•
•The record should indicate that 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
What kind of record is initiated when a patient is being transferred from the acute setting to another healthcare org?
When a patient is being transferred from the acute setting to another healthcare organization, a TRANSFER RECORD may be initiated.
A transfer record is also called a:
Referral form
What does a transfer record contain?
•A brief review of the patient’s acute stay along with
•Current status
•Discharge and transfer orders, and
•Any additional instructions will be noted
Who often completes portions of a transfer record or referral form?
Social service and nursing personnel often complete portions of the transfer record
Autopsy Report
An autopsy report is a description of the examination of a patient’s body after he or she has died
Autopsies are also called
When are autopsies usually conducted?
Autopsies are usually conducted when there is some question about the cause of death or when information is needed for educational or legal purposes.
What is the purpose of the autopsy report?
To determine or confirm the cause of death or to provide more information about the course of the patient’s disease
Who completes the autopsy report?
The autopsy report is completed by a pathologist and becomes part of the patient’s permanent health record
Who signs the authorization for the autopsy? And when must it be obtained?
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 also should become part of the record.
Obstetrics and Newborn Documentation: Each person admitted to a healthcare setting must have what?
A health record
When is a record on a newborn generated?
A record on a newborn is generated upon live birth.
A mother’s hospital obstetric record is:
Separate from the infant’s record and actually begins in her practitioner’s office
In the case of a baby born deceased, all information about the baby and the mother is maintained where?
In the case of a baby born deceased, however, all information about the baby and the mother is maintained in the mother’s health record
Obstetric delivery records include:
•A prenatal care summary provided by the practitioner’s office
•An admission evaluation by the attending physician to update the summary, and
•A record of labor, including information on contractions, fetal heart tones, an examination of the birth canal, medications given, and vital signs
The obstetric delivery record also includes:
•Type of delivery
•Medications administered, including anesthesia; •Description of the birth process, and any blood loss
•Evaluation of the placenta and cord; and •Information about any other delivery interventions
Other then in the birth record, where will data about the baby also be recorded? And what does it include?
Data about the baby also will be recorded in the mother’s record, including sex, weight, length, Apgar scores, any abnormal findings, and any treatments given
When do postpartum care records begin? What do they contain?
•Postpartum care records begin after the birth •They contain progress notes by physicians and nurses and other care providers
•In addition to the results of any diagnostic tests, treatments, and medications received by the mother
The newborn record begins with:
The birth history, which may be the same as or similar to the mother’s labor and delivery data noted above
Newborn identification generally includes:
Bands worn by both the mother and baby, which are regularly checked for matching information, and the infant’s footprints
What exam is completed shortly after birth?
A thorough newborn physical examination is completed shortly after the baby’s birth with periodic updates throughout hospitalization
What is part of the evaluation of all body systems in a newborn exam?
•Head and chest measurements are part of an evaluation of all body systems.
•Nursing documentation includes information on the baby’s feeding and elimination status, weight, vital signs, appearance, response to environment, sleeping patterns, and condition of the cord stump.
•Any special tests, treatments, and medications will also be noted
When will more extensive newborn documentation be found?
More extensive documentation will be found if a baby is born prematurely or requires intensive care services.
Administrative Data
As noted earlier in this section, an acute care health record contains the patient’s demographic and financial information as well as information about care provided.
How is the administrative information collected?
•Commonly, the administrative information is collected by hospital admitting personnel who personally ask the patient or the patient’s representative for the information needed to complete the admissions documentation.
•For elective admissions (ones that can be planned in advance) some information may be gathered in advance via a secure facility Web site or a telephone interview
For hospitals that maintain a paper-based health record system:
A printout of the admissions information is placed in the health record. In both paper-based and electronic health record systems, the admissions information then becomes a permanent part of the patient’s record. The admissions information may be referred to as a face sheet, a registration form, or a registration record
Demographic and Financial Information
•Demographics is the study of the statistical characteristics of human populations.
•In the context of healthcare, demographic information includes the following elements:
Patient’s full name
Patient’s facility identification or account number
Patient’s address
Patient’s telephone number
Patient’s date and place of birth
Patient’s gender
Patient’s race or ethnic origin
Patient’s marital status
Name and address of patient’s next of kin
Date and time of admission
Hospital’s name, address, and telephone number
The financial information maintained in the acute care health record is limited to:
The insurance information collected from the patient at the time of admission.
The insurance information collected from the patient at the time of admission, includes:
This information includes:
•The name of the expected payer
•The name of the policyholder (or insured)
•The gender of the policyholder
•The patient’s relationship to the policyholder
•The employer of the policyholder
•Individual and group insurance policy numbers •The patient’s Social Security number
Other Administrative Information: Some healthcare facilities place what in health records?
Some healthcare facilities place
•Property lists and birth and
•Death certificates in health records
•When a patient brings personal property and valuables to the healthcare facility, the facility may document them in the health record
•Items such as eyeglasses, hearing aids, prostheses, and other special medical equipment should be documented
•When items are kept in a secure location by the facility, that fact should be documented on the property/valuables list
What are birth and death certs used for? Who uses them? What are the content requirements?
•State governments use birth and death certificates to collect vital information and health statistics
•The content requirements vary somewhat according to relevant state law
•In some states, the certificates are prepared
by hospitals
•Copies of the certificates are often included
in patients’ health records
Consents, Authorizations, and Acknowledgments: What are healthcare providers required to obtain before they may provide invasive diagnostic procedures and surgical interventions, or release confidential patient information?
•Healthcare providers are required to obtain written consents or authorizations before they may provide invasive diagnostic procedures and surgical interventions or release confidential patient information.
•Acknowledgments usually apply to the patient’s confirmation that he or she has received specific information from the healthcare facility.
Consent to Treatment: Many healthcare facilities obtain a consent to treatment from patients or their legal representatives before what?
•Before providing care or services except in emergency situations
•This type of consent documents the patient’s permission for routine services, diagnostic procedures, and medical care
•However, privacy legislation has made this step a matter of facility choice
When was the first comprehensive set of federal rules dealing with health information privacy and security published? Who published?
In 2001, the Department of Health and Human Services (HHS) published the first comprehensive set of federal rules dealing with health information privacy and security.
Why were the rules for health information established by the dept of health and human services in 2001?
The rules were established to implement the provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and provide some uniformity to related practices across the country.
When did the final HHS health information privacy and security rule become effective? What did it permit?
•The final Privacy Rule became effective October 15, 2002.
•It permits all covered entities (those to whom the regulations apply) to use and disclose patients’ protected health information for their own treatment, payment, or healthcare operations and for the treatment, payment, and certain healthcare operations of other parties without prior written permission from patients or patients’ legal representatives.
What are covered entities?
Those to whom the regulations apply
What did HHS stress when it came to consents? And why would covered entities doe this?
•HHS stresses that covered entities may still voluntarily elect to obtain such consents.
•Many do because they are considered an integral part of healthcare professional ethical and practice standards.
What kind of discretion do covered entities have under the rules for health information established by HHS?
•Covered entities have complete discretion in designing their consent process if they choose this alternative. When a consent is obtained, it must become part of the patient’s record.
Authorizations Related to the Release and Disclosure of Confidential Health Information: what terms in the past were used almost interchangeably? What were they used to describe?
In the past, the terms “consent” and “authorization” were used almost interchangeably to describe an individual’s permission to disclose health information.
What did the terms consent and authorization used to refer to?
The terms referred to the written documentation of the patient’s formal permission to release his or her confidential health information to another party.
What did healthcare providers do as a standard practice in obtaining permission to disclose health info?
As a standard of practice, healthcare providers only obtained the individual’s permission to disclose health information when parties outside the organization were making the request.
HIPAA privacy legislation now applies the term authorization to mean what?
HIPAA privacy legislation now applies the term “authorization” to “permission granted” by the patient or the patient’s representative to release information for reasons other than treatment, payment, or healthcare operations.
When is the term “consent” now used?
The term consent is used when the permission is for treatment, payment, or healthcare operations.
An “authorization to disclose information” allows what? Who signs it?
•An authorization to disclose information allows the healthcare facility to verbally disclose or send health information to other organizations.
•The patient or his or her legal representative signs the authorization.
Under the HIPAA Privacy Rule, covered providers are required to obtain what?
Written authorization for the use or disclosure of protected health information for purposes not related to treatment, payment, or healthcare operation.
What does the HIPAA privacy rule establish?
•The HIPAA Privacy Rule establishes federal guidelines for the content and use of authorization forms.
•Guidelines also indicate who may provide consent and when an authorization can be revoked.
Individual state regulations as they relate to HIPAA:
•Individual states may have laws or regulations that define the content of authorizations.
•When such laws or regulations exist, the facility should consult the HIPAA Privacy Rule to determine how to apply the state requirements
•Usually the most restrictive guideline is the one followed
What is usually the most restrictive
Usually the most restrictive guideline is the one followed.
When does the HIPAA privacy rule require special handling?
•The HIPAA Privacy Rule also requires special handling when releasing some psychotherapy documentation.
•Many states also have laws and regulations that address the use and disclosure of behavioral health and psychotherapy records.
A federal confidentiality rule for alcohol and drug abuse treatment records applies to what?
Applies to the records of participants in federally assisted alcohol or drug abuse programs.
What other laws may the state and federal laws address?
Other laws may address those with the human immunodeficiency virus (HIV), acquired immune deficiency syndrome (AIDS), and other disorders.
If other laws and regulations are more stringent in protection of individual health information, how is HIPAA factored in?
If these other laws and regulations more stringently protect individual health information or provide the individual greater access or control over their protected health information, they will not be preempted by HIPAA.
What does the HIPAA privacy rule require most providers to obtain? And what might providers require?
•The HIPAA Privacy Rule requires most healthcare providers to obtain written authorization for specific disclosures not otherwise permitted by law.
•Healthcare providers may require patients to give their permission as a condition of treatment, and managed care organizations and health insurance plans may require authorization as a condition of service enrollment.
What is an Advance Directive?
An advance directive is a written document that names the patient’s choice of legal representative for healthcare purposes.
What is a designated person of an Advance Directive empowered to do?
The person designated by the patient is then empowered to make healthcare decisions on behalf of the patient in the event that the patient is no longer capable of expressing his or her preferences.
What are examples of Advance Directives?
Living wills and durable powers of attorney for healthcare are two examples of advance directives.
What physician’s orders should be consistent with the patient’s advance directives?
Physician orders for “do not resuscitate” (DNR) and “do not attempt intubation” (DNI) should be consistent with the patient’s advance directives.
Patient Self-Determination Act (PSDA):
The federal legislation that requires healthcare facilities to provide written information on the patient’s right to issue advance directives and to accept or refuse medical treatment
The federal Patient Self-Determination Act (PSDA) went into effect in what year?
What does the psda require?
The PSDA requires healthcare facilities to provide written information on the patient’s right to execute advance directives and to accept or refuse medical treatment.
Healthcare organizations that accept Medicare or Medicaid patients are required to adhere to the following provisions of the PSDA:
1. Healthcare organizations must develop policies that meet the requirements of state law regarding the patient’s right to accept or refuse medical treatment and to develop advance directives.
2. Upon admission, healthcare organizations must provide written information to the patient that describes the treatment decisions that patients may make and the hospital’s related policies.
3. Healthcare organizations must document the fact that the patient has an advance directive in his or her health record. However, they are not required to make a copy of the directive a permanent part of the patient’s health record
What are acknowledgment of patient’s rights forms used for?
•Acknowledgment forms are used to document the fact that information about the patient’s rights while under care was provided to the patient.
What is the Acknowledgment of Patient’s Rights also called?
•Referred to as the patient’s bill of rights
Medicare Conditions of Participation (or Conditions for Coverage) require hospitals to provide patients this info, and must include the right to:
•Know who is providing treatment
•Receive information about treatment
•Refuse treatment
•Participate in care planning
•Be safe from abusive treatment
What are the two common ways to document the receipt of rights info in the health record?
•First, the patient or his or her legal representative can sign a document to indicate that the patient received the bill of rights.
•Second, the facility can have the patient sign and date the actual bill of rights and place it in the health record.
1. What are factors in the differences and similarities among the health records maintained by different healthcare facilities?
1. One factor is the healthcare setting; (acute care, ambulatory care, long-term care, and so on)
2. It also depends on external factors such as which accreditation standards apply
2. Example of healthcare setting making a difference of health records maintained by diff healthcare facilities:
•For example, the records of residents in long-term care facilities often contain immunization records and must contain documentation of communication of patient’s rights. •Acute care records, in contrast, do not usually contain immunization records but do contain acknowledgment of receipt of a bill of rights.
3. External factor of why healthcare settings differ in records maintained in each facility:
1. For example, the Joint Commission (defn below) issues specific health information standards for acute care hospitals.
2. However, the standards of the Commission on Accreditation of Rehabilitation Facilities (CARF) are more frequently used by rehabilitation hospitals.
Joint Commission (TJC):
A private, not-for-profit organization that evaluates and accredits hospitals and other healthcare organizations on the basis of predefined performance standards; formerly known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Commission on Accreditation of Rehabilitation Facilities (CARF):
A private, not-for-profit organization that develops customer-focused standards for behavioral healthcare and medical rehabilitation programs and accredits such programs on the basis of its standards
The accrediting agencies for the practice settings discussed in this chapter and includes each organization’s Web site
•Accreditation Association for Ambulatory Health Care (AAAHC)
•American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
•Accreditation Commission for Health Care (ACHC)
•American Correctional Association (ACA)
•American Osteopathic Association (AOA)
•Centers for Medicare and Medicaid Services (CMS)
•Commission for the Accreditation of Birth Centers (CABC)
•Commission on Accreditation of Rehabilitation Facilities (CARF)
•Community Health Accreditation Program (CHAP)
•DNV (Det Norske Veritas)
•National Commission on Correctional Health Care (NCCHC)
•National Committee for Quality Assurance (NCQA)
•The Joint Commission
4. Factor of why healthcare settings differ in records maintained in each facility:
State and local laws in the facility’s specific geopolitical location also may affect record content.
5. Factor of why healthcare settings differ in records maintained in each facility:
•In addition, the content of records can be affected by the rules that apply to facilities that receive funding from the federal government.
•For example, some federal regulations only apply to healthcare facilities that treat Medicare enrollees.
6. Factor of why healthcare settings differ in records maintained in each facility:
•The content of health records also depends on the type of medical services the patient requires.
•For example, the content of the record for an obstetrics patient would be different from the content of the record for a neurosurgical patient.
7. Factors of why healthcare settings differ in records maintained in each facility:
•The content of health records also depends on the type of medical services the patient requires.
•For example, the content of the record for an obstetrics patient would be different from the content of the record for a neurosurgical patient. •Content also depends in part on the duration of medical services.
•For example, the content of a long-term rehabilitation record would be different from the content of an emergency services record.
•Health record content also may be affected by the traits of individual patients (for example, age, functional status).
•Finally, the complexity of the patient’s medical condition is yet another factor.
The delivery of emergency care services occurs primarily in:
Hospital-based emergency departments and freestanding urgent care centers.
Emergency care documentation is limited to:
Information about the patient’s presenting problem and the diagnostic and therapeutic services provided during the episode of care.
The services provided in emergency situations concentrate on:
Diagnosing the medical problem and stabilizing the patient
Although minor injuries and illnesses may require no further medical treatment, emergency patients often must be:
Referred to ambulatory care providers for follow-up care
ER patients who are seriously ill:
Seriously ill or injured patients are admitted to a hospital for ongoing acute care treatment.
What is important to document in emergency care records?
•Documenting instructions given to the patient
•Patient’s presenting complaint
•And assessment
Why is thorough emergency care documentation needed?
•Thorough documentation is needed to justify reimbursement, protect the facility or the patient in potential legal proceedings, and ensure continuity of care.
What information should be entered into the patient’s health record for each emergency care visit?
•Patient identification (or the reason it could not be obtained)
•Time and means of the patient’s arrival at the facility
•Pertinent history of the illness or injury and physical findings, including the patient’s vital signs
•Emergency care given to the patient prior to arrival
•Diagnostic and therapeutic orders
•Clinical observations, including the results of treatment
•Reports and results of procedures and tests
•Diagnostic impression
•Medications administered
•Conclusion at the termination of evaluation/treatment, including final disposition, the patient’s condition on discharge or transfer, and any instructions given to the patient, the patient’s representative, or another healthcare facility for follow-up care
•Documentation of cases when the patient left the facility against medical advice
Ambulatory care includes what kind of care?
Care provided in physicians’ offices, group practices, and clinics, as well as hospital outpatient, neighborhood health, public health, industrial health, and urgent care settings
Basic Ambulatory Documentation and data is similar to:
Many of the data found in ambulatory care setting records are similar to those found in acute care hospitals.
(Ambulatory setting) The registration record used in a physician’s office, includes:
The same demographic and financial information as a hospital admissions record.
When do records for ambulatory patients have much more limited content?
For special ambulatory patients, (such as those referred as outpatients to a hospital for special diagnostic testing that is only available there), (or those visiting a public health setting for immunizations), records may have much more limited content.
In general, documentation in ambulatory care patient records typically includes the following materials:
•Registration forms
•Problem lists
•Medication lists
•Patient history questionnaires
•History and physicals
•Progress notes
•Results of consultations
•Diagnostic test results
•Miscellaneous flow sheets (for example, pediatric growth charts and immunization records and specialty-specific flow sheets)
•Copies of records of previous hospitalizations or treatment by other healthcare practitioners
•Consents to disclose information
•Advance directives
Ambulatory care records, include several elements unique to the ambulatory setting, such as:
•Ambulatory records usually contain a “problem list” whose function is to facilitate ongoing patient care management
•Sometimes problems are separated into acute (short-term, such as otitis media) and chronic (such as diabetes mellitus) categories
•Some physician practices place information on the patient’s current prescription medications on the problem list
•Others maintain a separate medication list
What is referred to as a patient history questionnaire?
Some ambulatory practices also use a structured format to collect past medical history information from the patient: This is called a patient history questionnaire.
What is a problem list (in ambulatory care records)?
•The problem list describes any significant current and past illnesses and conditions as well as the procedures the patient has undergone.
•The problem list also may include information on the patient’s previous surgeries, allergies, and drug sensitivities
Most ambulatory care settings can earn accreditation from the following (who all have health information documentation standards):
Accreditation Association for Ambulatory Health Care (AAAHC), the Joint Commission, or the AOA
Which accreditation groups focuses on managed care organizations?
Accreditation by the National Committee for Quality Assurance (NCQA) and the American Accreditation Healthcare Commission/URAC
Do physician practices participate in voluntary accreditation programs? What about clinics and outpatient settings?
•Most physician practices do not participate in voluntary accreditation programs
•But some clinics, outpatient settings, and managed care organizations choose to do so.
(Obstetric/Gynecologic Care Documentation) Why do some ambulatory care records have additional requirements?
Because of the specialized services provided.
In general, documentation of obstetric care must include what?
•Comprehensive personal and family history
•A detailed physical examination report
•A treatment plan
•Patient instructions
Specifically, the following kinds of information should be maintained for both obstetric and gynecologic patients:
•Medical history
— Reason for visit
— Health status
— Dietary/nutritional assessment
— Physical fitness and exercise status
— Tobacco, alcohol, and drug usage
— History of abuse or neglect
— Sexual practices, including high-risk behaviors and method of contraception
•Physical examination
•Periodic laboratory testing, including Pap tests and mammography, cholesterol levels, and fecal blood tests
•Additional laboratory testing needed for high-risk groups, including:
— Hemoglobin levels
— Bacteriuria testing
— Fasting glucose testing
— Testing for sexually transmitted diseases
— HIV testing
— Tuberculosis skin testing
— Lipid profile
— Thyroid testing
— Colonoscopy
The American College of Obstetricians and Gynecologists (ACOG)
•As an additional resource, a physician specialty group
•Provides guidelines to members for perinatal and women’s healthcare that have implications for record content
Commission for the Accreditation of Birth Centers:
Commission for the Accreditation of Birth Centers: A group that surveys and accredits freestanding birth centers
Commission for the Accreditation of Birth Centers:
•Another group whose voluntary accreditation process includes perinatal documentation standards
Pediatric Care Documentation: The records of infants, children, and adolescents also require special content, these should include:
These ambulatory care records should include the following:
-Past medical history
-Birth history
-Nutritional history
-Personal, social, and family history
-Growth and development record
-Review of systems
In addition, the records should include: •Documentation of well-child visits and •Immunizations
•Visits for medical concerns
•Including any medications prescribed
Ambulatory Surgical Care Documentation: Operating Room records
The operating room (OR) records maintained by freestanding ambulatory surgery centers are very similar to those maintained by hospital-based surgery departments.
Specifically, Medicare regulations require that ambulatory surgery records include the following information:
-Patient identification
-Significant medical history and the results of the physical examination
-Preoperative studies (studies performed before surgery)
-Findings and techniques of the operation, including the pathologist’s report
-Allergies and abnormal drug reactions
-Record of anesthesia administration
-Documentation of the patient’s informed consent to treatment
-Discharge diagnosis
The ambulatory surgery record should also include:
Documentation of the patient’s course in the recovery room.
What do many ambulatory surgery centers do as a follow-up procedure after a surgery?
•Telephone patients at home after their surgery as a routine follow-up procedure
•The ambulatory surgery record for the patient should include records of these follow-up calls
In addition to the Joint Commission, the AOA, and the AAAHC, what else has standards that apply to this surgical setting?
•The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
What governs those that seek medicare reimbursement?
Conditions of Coverage for ambulatory surgical centers govern those that seek Medicare reimbursement.
Long-term care is provided in a variety of facilities, including the following:
•Skilled nursing facilities (SNFs)
•Subacute care facilities
•Nursing facilities (NFs) (also known as convalescent care centers)
•Intermediate care facilities (ICFs)
•ICFs for the mentally retarded/disabled (ICF-MRs)
•Assisted-living facilities
The regulations govern long-term care facilities have established what?
Have established strict documentation standards.
Most SNFs, NFs, and ICF-MRs long-term care facilities are governed by:
Both federal and state regulations, including the Medicare Conditions of Participation.
Assisted-living facilities are usually governed only by what?
State regulations.
Most long-term care providers do not participate in:
In voluntary accreditation programs, although the Joint Commission does have long-term care facility standards.
What are the health records of long-term care patients based on?
Ongoing assessments and reassessments of the patient’s (or resident’s) needs.
Who develops ongoing assessments in long-term care? How often is the plan updated?
•An interdisciplinary team develops a plan of care for each patient upon admission to the facility
•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.
In SNFs (Skilled nursing facility), what is the care plan based on, and what is the format called?
•In SNFs, the care plan is based on a format required by federal regulations.
•The care plan format is called the resident assessment instrument (RAI).
Resident assessment instrument (RAI):
•The RAI is based on the “Minimum Data Set (MDS) for Long-Term Care”
•A uniform assessment instrument developed by the Centers for Medicare and Medicaid Services to standardize the collection of skilled nursing facility patient data; includes the Minimum Data Set 2.0, triggers, and resident assessment protocols
•The RAI is a critical component of the health record
Minimum Data Set (MDS) for Long-Term Care:
The instrument specified by the Centers for Medicare and Medicaid Services that requires nursing facilities (both Medicare certified and/or Medicaid certified) to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident’s functional capacity
What does the overall RAI framework include?
•The overall RAI framework includes the MDS, triggers, utilization guidelines, and resident assessment protocols (RAPs).
•The patient is assessed and reassessed at defined intervals as well as whenever there is a significant change in his or her condition.
Resident assessment protocol (RAP):
A summary of a long-term care resident’s medical condition and care requirements
In addition to development of the care plan, Medicare uses the MDS form to do what?
•Determine reimbursement
•Many states also use it to determine Medicaid payments, and accreditation surveyors use information from it during the survey process
How is the MDS submitted, and who does it go to?
•The MDS is submitted electronically to •each state health department and then on to the •Centers for Medicare and Medicaid Services (CMS).
What is done at CMS?
Demographic and quality indicator information is compiled and provided as feedback to each facility.
What is the role of the physician in a long-term care facility?
•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, which includes the medications and treatments provided to the resident
•He or she then visits the resident in the facility 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’s orders and makes changes as necessary.
•Between visits, the physician is contacted when nursing identifies changes in the resident’s condition.
What other specialized assessments and interdisciplinary progress notes are included in the long-term care health record?
The following list identifies the most common components of long-term care records:
•Identification and admission information
•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/MDS and care plan
•Physician’s orders
•Physician’s progress notes/consultations
•Nursing or interdisciplinary notes
•Medication and records of other monitors, including administration of restraints
•Laboratory, radiology, and special reports
•Rehabilitation therapy notes (physical therapy, occupational therapy, and speech therapy)
•Social services, nutritional services, and activities documentation
•Discharge documentation
If paper-based records are found in a long-term setting,what may occur at intervals during the patient’s stay?
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?
•Records of patients whose stay extends to months or years become cumbersome to handle
•Selected material may be removed and filed elsewhere according to facility guidelines
•Any material removed must remain accessible when needed for patient care and service evaluation.
Home Healthcare Documentation:
Home health agencies
Home health agencies provide medical and nonmedical services in the patient’s home or place of residence
What are the reasons for the increase in home health care?
•Home healthcare has seen an increase in the volume of patients due to
•Growth in the aged population,
•The desire of Americans to live at home as long as possible, and
•Cost savings over residential settings such as long-term care facilities
Describe regulations and accreditation for home care agencies?
•Federal regulations govern the home care agencies that accept Medicare enrollees.
•States also have licensure regulations for home care agencies.
•Organizations such as:
•The Joint Commission
•The Community Health Accreditation
Program (previously associated with the
National League for Nursing but now
operating independently), and
•The Accreditation Commission for
Health Care (ACHC) also provide
accreditation services for some home
health agencies
What agency has established documentation requirements? What else do they mandate?
•Medicare regulations and accreditation standards have established documentation requirements
•They also mandate periodic assessments.
What is different about agencies that are certified for medicare?
•For agencies that are certified for Medicare, the home health certification/plan of care is a central component of documentation.
•This document is a plan of treatment established by a physician.
What does the medicare home health certification/plan detail? How often is it reviewed? Renewed?
•The document is est. by a physician
•Details the patient’s diagnoses, •Impairments, goals, rehabilitation potential, and the type and frequency of services to be provided
•The physician reviews and renews the home health certification/plan of care at least once during a 60-day episode.
What is done between renewals of a medicare home health care certification?
Between renewals, certification is updated via the physician’s telephone orders.
Are there requirements for physician visits in home health care?
There are no requirements for physician visits in home care; patients are responsible for seeing their physicians as necessary.
What standardized patient assessment does medicare-certified home health care use?
Medicare-certified home healthcare also uses a standardized patient assessment instrument called the Outcomes and Assessment Information Set (OASIS).
What are OASIS items a component of? When is OASIS completed? What is OASIS the basis of?
•OASIS items are a component of the comprehensive assessment that is the foundation for the plan of care.
•OASIS is completed:
•At the start or resumption of care
•With each 60-day episode
•With a significant change in condition
•And upon patient transfer or discharge
•It is the basis for reimbursement under Medicare.
What standardized patient assessment instrument is the basis for reimbursement under medicare?
OASIS assessment
•The assessment is updated regularly and
•A new version, OASIS-C, was implemented January 1, 2010
How is OASIS submitted, and who receives?
•OASIS is submitted electronically to the state health department and then to CMS.
Describe the OASIS service agreement, how is it unique?
Unique to home care is a service agreement that details the type and frequency of services, the charges for the services, and the parties responsible for payment.
Other documentation in a home care record is driven by?
•The services ordered by the physician and agreed to by the patient
•Each visit to the patient is documented in his or her health record
•Documentation is also necessary for Home health aides assisting the patient with activities of daily living such as bathing and housekeeping, which allows the patient to remain at home
Some parts of home care records may be kept where? How is this beneficial?
•Some parts of records can be kept In the patient’s home
•To facilitate communication among multiple caregivers or services
•Technology has affected home care documentation through the use of portable computers such as laptops and personal data assistants (PDAs).
The home care record usually includes the following types of documentation:
1. Initial database/demographics and service agreement
2. Certification and plan of treatment
3. Physician’s orders
4. Documentation by each discipline involved in home care including treatment plans, summaries, and other progress notes
5. Comprehensive assessment (OASIS-C), plan of care, and case conference notes
6. Consents and other legal documents
7. Referral or transfer information from other facilities
8. Discharge summaries
How is hospice care is similar to home care? What is different?
•Hospice care is similar to home care in that most services are provided to patients in their homes.
•Hospices also may be located in other healthcare settings such as hospitals or long-term care facilities or in separate freestanding facilities
How is hospice unique? What does this type of care focus on?
•Hospice care is unique in that a hospice program provides palliative care to terminally ill patients and supportive services to patients and their families.
•This type of care focuses on symptom management (for example, pain) and patient comfort rather than life-prolonging measures.
When the patient is admitted to a hospice care program:
•His or her primary caregiver is identified
•Basic patient identification information, diagnoses, prognosis, attending physician, and emergency contact information are collected.
Who establishes a plan of care in hospice? What is this team considered?
•An interdisciplinary team establishes a plan of care, which is the foundation for the hospice services to be provided to the patient.
In hospice, what is the care plan based on?
•The care plan is based on information collected in the physical and psychosocial assessments performed upon admission. •The assessments are updated throughout the patient’s participation in the program.
How often is documentation of a care plan reviewed in hospice? What do federal regulations require?
•Documentation of a care plan review is required every 30 days.
•The hospice provider must prepare a summary when the patient is transferred between care settings (between hospital and home care, for example)
•Federal regulations require the hospice provider to follow the patient’s care plan even when the patient receives inpatient services.
What governs hospice providers? What are accreditation documentation req’s based on?
•Federal regulations govern hospice providers, as do •accreditation standards established by the same organizations noted under home healthcare documentation
•As might be expected, accreditation documentation requirements are based on federal regulations, so the content of all is similar.
The payment rate for hospice services is based on?
Directly on the services provided and the level of care needed as documented in the health record
Two basic episodes in hospice care:
1. The first episode begins with the patient’s admission to the program and ends when the patient dies, is discharged, or is transferred to another facility
2. The second begins with the patient’s death and follows the family through the bereavement process until the survivors are discharged. Bereavement services can last as long as one year and must be documented.
Behavioral healthcare is delivered:
Inpatient hospitals
Outpatient clinics
Physicians’ offices
Rehabilitation programs, and
Cmmunity mental health programs
Behavioral healthcare documentation reflects what?
The type of facility and the level of care and services delivered.
For example, an inpatient psychiatric hospital maintains documentation similar to an inpatient hospital in addition to documentation unique to behavioral health.
Following are the common inpatient setting documentation requirements for behavioral health settings as established by the Joint Commission and federal regulations:
•Identification data
•Source of referral
•Reason for referral
•Patient’s legal status
•All appropriate consents for admission, treatment, evaluation, and aftercare
•Admitting psychiatric diagnoses
•Psychiatric history
•Record of the complete patient assessment, including the complaints of others regarding the patient as well as the patient’s comments
•Medical history, report of physical examination, and record of all medications prescribed
•Provisional diagnoses based on assessment that includes other current diseases as well as psychiatric diagnoses
•Written individualized treatment plan
Documentation of the course of treatment and all evaluations and examinations
•Multidisciplinary progress notes related to the goals and objectives outlined in the treatment plan
•Appropriate documentation related to special treatment procedures
•Updates to the treatment plan as a result of the assessments detailed in the progress notes
•Multidisciplinary case conferences and consultation notes, which include date of conference or consultation, recommendations made, and actions taken
•Information on any unusual occurrences such as treatment complications, accidents or injuries to the patient, death of the patient, and procedures that place the patient at risk or cause unusual pain including restraints and seclusion
•Correspondence related to the patient, including all letters and dated notations of telephone conversations relevant to the patient’s treatment
•Discharge or termination summary
Plan for follow-up care and documentation of its implementation
•Individualized aftercare or post-treatment plan
Groups that also have standards for facilities that specialize in mental health, mental disabilities, or developmental disabilities:
CARF, the Council on Quality and Leadership in Support for People with Disabilities, and AOA
Rehabilitation Services focus:
The focus of services in physical medicine and rehabilitation settings is increasing a patient’s ability to function as independently as possible within the parameters of the individual’s illness or disability.
Rehabilitation Services Documentation
•The documentation requirements for rehabilitation facilities vary because facilities range from comprehensive inpatient care to outpatient services or special programs
•Health record documentation reflects the level of care and services provided by the facility.
Inpatient rehabilitation hospitals and rehabilitation units within hospitals are reimbursed by:
Medicare under a prospective payment system based on documentation.
A ________ ________ is completed shortly after admission and upon discharge
Patient assessment instrument (PAI)
This is: A standardized tool used to evaluate the patient’s condition after admission to, and at discharge from, the healthcare facility
What is a payment level based on in rehab services healthcare facility?
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 (CORF) have separate Medicare guidelines]
Many rehabilitation facilities are accredited through? What do they require?
•CARF, although the Joint Commission or 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:
•Identification data
•Pertinent history, including functional history
•Diagnosis of disability/functional diagnosis
•Rehabilitation problems, goals, and prognosis
•Reports of assessments and individual program planning
•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
•Patient’s total program plan
•Plans from each service
•Signed and dated service and progress reports
•Correspondence pertinent to the patient
•Release forms
•Discharge report
•Follow-up reports
Correctional facilities often provide health services to those incarcerated and thus maintain health records:
•Prisons, jails, and juvenile detention centers are all examples of correctional facilities
•Health records at those sites begin with the collection of certain baseline information obtained during the initial intake process
•This information may include a history and physical, a chest x-ray, and laboratory testing as well as a dental examination and a psychological evaluation
Additional information is added to the inmate’s health record when he or she visits:
•Health services for treatment of illness or injury, therapy, or medication
•Examples include interdisciplinary progress notes and physician’s orders
•Of note is the rule that inmates may not maintain their own over-the-counter medications
•Thus, even these types of medications must be received from health services and documented in the health record.
Because some inmates are imprisoned for many years, paper records eventually may include:
•Numerous volumes
•Therefore, health information staff must develop and adhere to procedures that keep the most current and comprehensive information readily available
As a result of inmate’s original paper-based health record being transferred with the inmate when he or she moves to a different prison within the state system:
•HIM professionals in such states must work together to produce standardized policies, procedures, and formats
•Federal facilities often have similar practices
•Electronic records will certainly have an impact, but the need for coordination among sites remains
Correctional health services may choose to comply with:
1. The general standards of the Joint Commission
2. The focused basic standards developed by the American Correctional Association
3. Or the more comprehensive standards of the National Commission on Correctional Health Care
(All have accreditation programs for correctional facilities)
Individuals with severe kidney disease requiring renal dialysis may be treated in:
1. Outpatient settings of healthcare facilities
2. Independent dialysis centers, while residents of long-term care settings
3. Or even in their own homes (self-dialysis).
End-Stage Renal Disease Service Documentation:
Medicare has specific Conditions for Coverage that apply to all these settings. The standards include criteria for record content as well as for record keeping.
End-Stage Renal Disease documentation begins with:
•Notification of patient rights
•A unique component of that notification is the inclusion of: information on the facility’s policy for hemodialyzer reuse.
End-Stage Renal Disease treatment record elements include:
•An interdisciplinary patient assessment
•A plan of care, with team members commonly consisting of a physician, nurse, social worker, registered dietitian, and the patient
•Progress notes
•Laboratory test results
•A discharge summary
•And consents also must be found
Special emphasis is placed on:
•Recording the patient’s nutritional,
anemia, vascular access, transplant, and
•Rehabilitation status, as well as
•Social service interventions and dialysis
(End-Stage Renal Disease) Evidence of both of the following must also be documented:
Patient education and training are important for dialysis success and for continued service
Documentation Standards: The importance of documentation to the quality of direct patient care
•Documentation represents the primary communication among multidisciplinary caregivers for efficient and effective initial treatment, for continuing care, and for the evidence that care and treatment occurred.
•Documentation promotes understanding of the whole patient in the long term.
What do HIM professionals help healthcare organizations?
•Health information management (HIM) professionals provide a valuable service in helping healthcare organizations to establish reasonable documentation policies and procedures
•A well-executed approach satisfies numerous needs and interests, including those of the provider, the healthcare consumer, and external parties.
What indirect benefits do timely and effective documentation have beyond patient care?
•Performance improvement and risk management activities rely heavily on health record documentation
•These activities result in direct improvements in patient care and operational processes
•Also, healthcare organizations use cumulative health data as the basis for making decisions on future services.
Health record documentation also is reviewed by external organizations.
What do regulatory agencies use documentation as?
•Regulatory agencies use documentation as a tool to measure the quality of services before granting accreditation or certification to healthcare organizations
•Third-party payers depend on documentation as proof that chargeable services were actually received.
Why does the legal system search the written record for evidence?
It is generally assumed that a service that was not documented was not done.
Basic Principles of Health Record Documentation
•The basic principles of health record documentation apply to both paper-based and electronic patient records
•The principles address the uniformity, accuracy, completeness, legibility, authenticity, timeliness, frequency, and format of health record entries
The American Health Information Management Association (AHIMA) has developed the following general documentation guidelines for the 1. basic principles of the health record (Smith 2001):
1. 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.
2. Guidelines of the health record est by AHMA:
2. The health record should be organized systematically in order to facilitate data retrieval and compilation
3. Guidelines of the health record est by AHMA:
3. Only individuals authorized by the organization’s policies should be allowed to enter documentation in the health record.
4. Guidelines of the health record est by AHMA:
4. Organizational policy and/or medical staff rules and regulations should specify who may receive and transcribe verbal physician’s orders
5. Guidelines of the health record est by AHMA:
5. Health record entries should be documented at the time the services they describe are rendered
6. Guidelines of the health record est by AHMA:
6. The authors of all entries should be clearly identified in the record.
7. Guidelines of the health record est by AHMA:
7. Only abbreviations and symbols approved by the organization and/or medical staff rules and regulations should be used in the health record.
8. Guidelines of the health record est by AHMA:
8. All entries in the health record should be permanen
9. Guidelines of the health record est by AHMA:
9. 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.
10. Guidelines of the health record est by AHMA:
10. Any corrections or information added to the 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 an addendum.
11. Guidelines of the health record est by AHMA:
11. The HIM department should develop, implement, and evaluate policies and procedures related to the quantitative and qualitative analysis of health records
Uniform specific documentation guidelines for EHRs:
•Are not yet developed
•In the interim, HIM practitioners continue to apply basic documentation principles to every medium.
The type of medium, paper or electronic, may require:
•That specific details be handled differently to achieve the same documentation goals.
•For example, the method used to make corrections and amendments in EHRs may be different from the method used for paper-based records.
•In fact, in 2009 AHIMA published Amendments, Corrections, and Deletions in the Electronic Health Record Toolkit. The publication includes definitions of each term, case scenarios, and practice guidelines.
•Additional resources such as this toolkit will assist practitioners with EHR implementation
A number of laws, regulations, and standards requiring minimum levels of documentation exemplify:
•The importance of high-quality documentation outside the organization as well as within.
•Healthcare organizations must comply in order to maintain licensure within their states, to remain certified for federal program reimbursement, to maintain current accreditation status with external agencies, and to avoid fines.
When developing documentation policies and practices, the healthcare organization is usually obligated to simultaneously follow:
•Legal, regulatory, and accreditation directives that pertain to its particular facility type within its geopolitical area
•Generally, following the strictest directives that apply ensures adequate compliance
•In all cases, the ultimate goal is quality of care for patients in every healthcare environment
Significant overlap exists among the documentation requirements of accrediting bodies and?
Federal and state regulations and laws (Although overlap may exist, differences among the standards must be recognized)
When determining its policies, the organization must do what?
•Evaluate all relevant standards •Documentation requirements are usually recorded in medical staff rules and regulations and become a component of medical staff membership requirements
Standards for Health Record Documentation: What are four main sources for documentation guidelines?
1. Facility-specific standards
2. Licensure requirements
3. Government reimbursement standards
4. Accreditation standards
Facility-specific standards vary widely and are beyond the scope of this text:
A description of alternatives available in the remaining categories follows:
State Regulating Agencies
•Individual states pass legislation and mandate regulations that affect how healthcare organizations within them operate and care for patients
•Compliance with state licensing laws is required in order for healthcare organizations to begin or remain in operation within their states
•To continue licensure, organizations must demonstrate their knowledge of, and compliance with, documentation regulations.
Medicare and Medicaid Programs
•Administered by the federal government Centers for Medicare and Medicaid Services (CMS)
•The Medicare Conditions of Participation or Conditions for Coverage apply to a variety of healthcare organizations that participate in the Medicare program
•Regulations vary according to setting and address documentation conditions that must be met to continue participation
Medicare and Medicaid Program standards currently exist for:
•Hospitals, including rural hospitals, skilled and other nursing facilities, home health agencies, hospices, rehabilitation facilities, qualified health centers, some outpatient or independent therapy services, and some behavioral health providers including those focused on substance abuse
•Conditions for Coverage apply to Suppliers of End Stage Renal Disease (ESRD) Services and ambulatory surgery centers.
Conditions for coverage:
•Medicare recognizes some accreditation organizations as having standards that sufficiently cover the related Conditions of Participation
•After reviewing the standards of accrediting groups that seek this recognition, Medicare may award them “deemed status”
Deemed status:
An official designation indicating that a healthcare facility is in compliance with the Medicare Conditions of Participation; to qualify for deemed status, facilities must be accredited by the Joint Commission on Accreditation of Healthcare Organizations or the American Osteopathic Association
When are separate Medicare surveys not required?
•As long as a healthcare setting maintains active accreditation by an accreditation body with deemed status
•For all other settings, surveys are performed
Who are medicare surveys contracted to?
This task is often contracted to state government health reviewers.
Medicaid programs
•Programs are funded jointly by federal and state governments but are administered by the individual states
•Guidelines vary from state to state
•Similar to Medicare participation, facilities are often required to meet federal Conditions of Participation or Conditions for Coverage to receive these funds
Accreditation Organizations: Many healthcare organizations seek public recognition through
•Accreditation with recognized accrediting bodies
•This status signifies that the facility has met patient care and other standards for providing high-quality care
•In some cases, it also allows facilities to participate in programs that affect their financial status, such as Medicare and Medicaid, Medical Resident Programs, and other training programs
Organizations seeking accreditation must meet specific documentation standards
•Periodic surveys and detailed record review by the accrediting body evaluate how well the organization is complying with documentation standards
•Standards are reviewed by the sponsoring body on a regular basis, usually every one to three years, with updates made as needed
Healthcare organizations voluntarily seek accreditation from a variety of private, not-for-profit accreditation organizations
•Different types of organizations are accredited by different accreditation organizations
A number of healthcare settings are eligible for Joint Commission accreditation, including:
Hospitals (acute, critical access, children’s, psychiatric, and rehabilitation), ambulatory care organizations, behavioral health organizations, home care including hospice providers, long-term care facilities, clinical laboratories and pharmacies, and medical equipment providers.
Additional specialty settings are eligible for:
•Joint Commission certificate programs
•Examples include disease-specific programs and advanced care settings such as primary stroke or diabetes centers
•As an additional benefit for its accredited organizations, the Joint Commission has earned CMS deemed status
The Joint Commission
•Beginning with its acute hospital standards in 2004, the Joint Commission:
•Initiated a new process that moved from survey monitors every three years to •a philosophy of continuous improvement and continuous standard compliance
Results of the joint commission:
•Standards were streamlined and survey paperwork reduced
•Facility monitoring of sentinel (unexpected) events was encouraged
•And following the hospital experience of selected patients (tracer methodology) during its surveys was instituted
•Each accreditation standard was accompanied by a rationale and steps to meet the standard, called “elements of performance”
“elements of performance”
When each accreditation standard isaccompanied by a rationale and steps to meet the standard
What was implemented in 2006 in support of continuous improvement philosophy:
•Unannounced on-site surveys were implemented in 2006
•Along with a priority focus process that assists surveyors in conducting reviews that focus on issues that are important for safety and quality of care
•Annual submission of a periodic performance review helps facilities evaluate compliance
•In 2007 and 2008, hospital standards:
•In 2007 and 2008, hospital standards once again went through an improvement process, and in 2009 a new scoring method was introduced that takes into consideration the criticality of a requirement (Rollins 2008).
What commission eventually adopted the new methods in many of their accred programs?
The Joint Commission implements most changes in standards or the accreditation process with its hospital accreditation program, but eventually adopts the new methods in many of its accreditation programs.
Why did the joint commission eventually adopt new methods?
The Joint Commission recognizes the appropriateness of applying documentation standards consistently across the healthcare continuum and has identified a number of common standards that apply to all healthcare settings.
Frequently, these core expectations are supplemented by additional standards that represent the specific requirements of different settings and services.
For example, a teaching hospital that hosts medical education programs for residents would be evaluated on its compliance with standards for supervision of residents, in addition to common standards and standards specific to acute care settings.
As of 2009, many standards that apply to health records have been moved from:
•The prior Management of Information and other sections and consolidated in a Record of Care, Treatment and Services chapter (Rollins 2008).
•To ensure compliance with all health information standards, review of all sections and monitoring of all standards that are found is important
•This concept applies to standards of other accreditation organizations as well.
The Joint Commission also has addressed:
•Errors in interpretation of abbreviations commonly used in health records by publishing a prohibited abbreviation list. •The abbreviations noted on the list should not be found in the patient health records of their accredited health providers.
American Osteopathic Association (AOA)
•AOA first initiated its hospital accreditation program to ensure the quality of residency programs for doctors of osteopathy.
•Today, its Healthcare Facilities Accreditation Program (HFAP) accredits a number of additional healthcare organizations and facilities, including acute, specialty, and critical access hospitals; laboratories; and ambulatory care/ambulatory surgery, behavioral health, substance abuse, physical rehabilitation medicine, and stroke centers
AOA documentation standards
•Documentation standards are both broad (as they pertain to common documentation requirements) and specific (as they address specialty services). The HFAP also holds Medicare deemed status
Accreditation Association for Ambulatory Health Care (AAAHC)
•AAAHC has established standards that are similar to common acute care documentation practices
•The standards emphasize summaries for enhancing the continuity of care
AAAHC standards emphasizing summaries for enhancing the continuity of care is especially important for who?
•This is especially important for the ambulatory patient
•For example, summaries of past surgeries, diagnoses, and problems are helpful in transferring history information to new treatment settings for complex cases.
•A wide variety of
Ambulatory care facilities
Managed care organizations, and
Office-based surgical centers qualify for specific AAAHC accreditation programs.
•The latter two programs hold CMS deemed status
Commission on Accreditation of Rehabilitation Facilities (CARF)
•CARF accredits
Rehabilitation programs and services in medical rehabilitation
Care for the aging
Behavioral health
Children and youth services
Employment and community services, Opioid treatment
Vision rehabilitation, and
Business networks
CARF Health record documentation is used to evaluate:
Procedural issues surrounding special circumstances in the treatment and handling of patients and clients
National Committee for Quality Assurance (NCQA)
•NCQA began accrediting managed care organizations in 1991
•The NCQA standards focus on patient safety, confidentiality, consumer protection, access to services, service quality, and continuous improvement
More recently, NCQA expanded its program to include:
other types of organizations, such as preferred provider, wellness and health promotion, and managed behavioral health organizations
A number of other organizations accredit specific types of healthcare facilities that focus on specific ambulatory or managed healthcare settings:
•The Commission for the Accreditation of Birth Centers
•The American Association for Accreditation of Ambulatory Surgery Facilities, and
•The American Accreditation Healthcare Commission/URAC
The Accreditation Commission for Health Care and the Community Health Accreditation Program accredit:
Home health and hospice organizations.
Correctional institutions can choose to have health services:
Reviewed by the National Commission on Correctional Health Care and the American Correctional Association
Where can standards that affect health record content be found?
Standards that affect health record content can be found in the guidelines for all accreditation programs
Beginning in 2008, the DNV (Det Norske Veritas), an international accrediting organization, began:
•A hospital accreditation program in the United States
The DNV standards program, referred to as the National Integrated Accreditation for Healthcare Organizations (NIAHO)
•Incorporates international quality management standards (ISO 9001) and
•The Medicare hospital Conditions of Participation
Although just gaining acceptance in the United States, its CMS deemed status and quality focus have been positively received.
Health records are maintained in two basic formats:
•Paper-based or electronic
Records are referred to as ______ if they have some paper and some electronic components
Paper-Based Health Records: The traditional paper-based health record format has several limitations:
•Because the paper-based record is lengthy and difficult to handle, management most often chooses to keep it in a single format that all end users can agree on
•The greater the number of end users, the more important it is to follow a defined format
•One format is also supported by accreditation standards and state licensure regulations that require every provider to develop specific guidelines on how the information in health records is to be arranged
•State laws, regulations, and accreditation standards also require specific content elements
Although the regulatory standards regarding content also apply to electronic records, the foundation of an EHR is defined data elements:
•In a true EHR, computer screen views can be tailored to the needs of the end user.
•The paper-based record does not allow
for this individual customization
•In addition, the EHR allows the system administrator to limit access to information, restructure information, and highlight key information that the end user may need.
•The paper-based record lacks such
formatting flexibility
Three major types of paper-based health records are in use today:
Source-oriented health record
Problem-oriented health record
Integrated health record
It is important to realize, however, that no hard and fast rules exist for:
•Arranging the elements of a health record. •The healthcare provider is free to select the arrangement that best suits its needs. •For example, some organizations arrange the materials in active paper-based records in one way and closed records in another
Source-Oriented Health Records
•Documents are grouped together according to their point of origin
•Laboratory records are grouped together, radiology records are grouped together, clinical notes are grouped together, and so on.
•Thus, physicians’ progress notes for a single episode of patient care would be arranged in either chronological or reverse chronological order and placed together in the patient’s health record
Results of Source-Oriented Health Records
•Those individuals charged with filing reports in the paper-based health record can do so easily simply by looking at the source and date of the report
•However, the end users of information filed in the record do not have as easy a time
•To follow information on the patient’s course of treatment, they must search by date of occurrence in each of the groups of information (that is, laboratory, radiology, and every group of clinical notes)
•The more departments a facility has, the more sections a source-oriented health record can have
•It is left to the end user to tie together information from the various sections of the record to get a picture of the entire course of treatment
Problem-Oriented Health Records
The problem-oriented health record is better suited to serve the patient and the end user of the patient information
•The key characteristic of this format is an itemized list of the patient’s past and present social, psychological, and medical problems
•Each problem is indexed with a unique number
In addition to a problem list, each problem-oriented health record contains:
•A database, the initial care plan, and progress notes.
•The database is formatted much like the source-oriented health record and contains the following information:
Chief complaint
Present illness(es)
Social history
Medical history
Physical examination
Diagnostic test results
The Problem-Oriented Health Records initial plan:
•Serves as an overall road map for addressing each of the patient’s problems. •The plans are numbered to correspond to the problems they address
•The patient’s healthcare provider uses progress notes to document how the patient’s problems are being treated and how he or she is responding to treatment
•Each progress note is labeled with the unique number assigned to the problem being addressed
•Some providers also use a SOAP format for their problem-oriented progress notes:
•A subjective (S) entry relates significant information in the patient’s words or from the patient’s point of view
•Objective (O) data includes factual information such as laboratory findings or provider observations
•Professional conclusions reached from evaluation of the subjective or objective information make up the assessment (A) •And any comments on or changes in plans (P) complete the framework
•Not all SOAP components must be entered in every note. If the SOAP framework is used, only pertinent parts are documented. •This problem-indexing system allows the healthcare provider to easily follow the patient’s course of treatment regarding any specific problem
•Ideally, other elements of the health record (for example, physician’s orders) also would be numbered according to the problems they address
Integrated Health Records
•Third major type of paper-based health record is the integrated health record
•Arranged so that the documentation from various sources is intermingled and follows strict chronological order.
•Advantage of the integrated format is that it is easy to follow the course of the patient’s diagnosis and treatment
•Disadvantage is that the format makes it difficult to compare similar types of information
How has the quality of healthcare records improved?
•Advances in standardized format, •Standardized medical terminology, and •Improved information capture and delivery have improved the quality and value of the health record.
Weaknesses of the paper-based health record:
•Various quality, standardization, and timeliness issues need to be addressed and resolved
•For example, the average health record is needed by approximately 150 end users. •However, the paper-based health record can be viewed by only one user at a time and in only one place at a time
•Thus, the valuable information recorded in the health record is often unavailable to individuals who need it
Addtnl weaknesses of the paper-based health record:
•Paper-based health records can be difficult to update
•An active record of a patient receiving care moves often from provider to provider within the healthcare facility
•The individual(s) responsible for updating its content must hand-carry paper documents to wherever the record is located in order to file them or wait until the record is returned
•The result is that updates may be delayed
More weaknesses of the paper-based health record:
•Finally, paper-based health records are fragile and susceptible to damage from water, fire, and the wear and tear of daily use
•They also can easily be misplaced or misfiled
•For most organizations, it would be prohibitively expensive and difficult to maintain duplicate copies of paper health records as backups.
•For all of these reasons and the need to provide better coordinated services, reduce medical errors and duplication of services, and consequently increase the quality of care, national efforts are focused on the adoption of electronic health records
Definition of the Electronic Health Record:
•Initial work in developing a definition of an electronic health record came through efforts to identify its functions
•Work by the Institute of Medicine (IOM) began that process by identifying eight core functions
•In July 2004, using the IOM’s work as a foundation, a national standards group called Health Level Seven (HL7) introduced a list of about 130 different functions that would help define an EHR
Although these efforts contributed to the understanding of electronic health records, a uniform, consistent definition still did not exist.
In fact, a literature review conducted as part of a project of the National Alliance for Health Information Technology (NAHIT) found close to 90 unique definitions for electronic health/medical records (NAHIT 2008)
To address the important task of uniformity in definitions, the Office of the National Coordinator for Health Information Technology charged a workgroup to tackle the topic.
•NAHIT published its report in April 2008. •The report includes proposed definitions for electronic medical records, electronic health records, and personal health records
•EHR report differentiates between electronic medical and electronic health records as follows:
•Electronic medical record—an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health organization.
•Electronic health record—an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization
Thus, the suggestion is that the term “electronic health record” be applied to:
•Those record systems that support the function of interoperability across healthcare providers.
•The group also addressed uniformity in network terminology
•And provided suggested definitions for health information exchanges, health information organizations, and regional health information organizations
initial seminal efforts on describing an electronic health record system were sponsored by the Institute of Medicine.
•A Committee on Data Standards for Patient Safety made up of members from the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine
•Released a report in 2003 entitled “Key Capabilities of an Electronic Health Record System”
The “Key Capabilities of an Electronic Health Record System,” identified eight core functions. These core functionalities are:
•Health information and data—patient data using defined data sets and interfaces with related medical treatment and diagnostic reporting systems
•Results management—electronic reporting of tests, consultations, and related patient consents
•Order entry and management—electronic order entry with allergy, interaction, and laboratory report interfaces
•Decision support—reminders, prompts, diagnosis and disease management information, adverse event, disease outbreak, and bioterrorism tracking
•Electronic communication and connectivity—exchange of healthcare data across providers within and outside a care setting to support continuity of care, including telemedicine and telemonitoring options
•Patient support—patient education and home-based telemedicine opportunities
•Administrative processes—electronic scheduling, billing and claims management, and identification of those appropriate for clinical trials or focused disease management
•Reporting and population health management—quality management and regulatory reporting (IOM 2003)
There has been considerable evidence of the progression toward
Interoperable electronic health records since the report was published, but much work remains.
Electronic Health Record Technologies: Databases and Database Management Systems
•Most electronic records are organized according to one of two unique database models—
•The centralized record and the
•Distributed record
•Or a mix of the two models
Whichever model is used, it is important that the systems be able to communicate and share data elements
In the centralized model
Patient health information and data are stored in a single central computer system
In the distributed model
Patient health information and data are located in department-based computer systems or subsystems.
Data Input: Creating a workable data capture process has proved to be one of the major challenges facing EHR implementers.
•Transcription remains the most common type of data input mechanism
•The end user either inputs the information or dictates it in report style to be transcribed.
•Alternative data capture tools are being developed or refined to address the challenge of creating workable data capture processes.
•Among these technologies are the following:
Continuous voice recognition
Optical character readers
Barcode readers
Document imaging
Automated templates
Structured data entry
In an ideal situation, the individual responsible for providing the service or treatment enters the data into the database:
At or near the time the service or treatment occurs. When recorded, the information is immediately available to all end users on a need-to-know basis.
Image Processing and Storage
•The traditional paper-based health record included few photographs and diagnostic images.
•However, with the introduction of imaging technology, it is now possible to combine health record text files with diagnostic imaging files.
•This development has created the multimedia health record
Electronic imaging has other advantages.
•For example, because the actual images never leave the control of the system administrator, lost files become rare.
•In addition, medical imaging allows more than one end user to view a document at the same time.
•Further, the digitized files make it possible to transfer images to remote locations quickly and easily.
Text Processing and Data Retrieval:
•Retrieving a single piece of information from a paper record can require a lot of time and effort.
•The introduction of electronic applications has improved text searching and retrieval because files now can be indexed
•In fact, the ultimate goal of any EHR system is to quickly deliver useful health information to the end user in the location where it is most needed
•The most effective approach considers the end user’s needs
•In addition, the introduction of database systems using query language applications allows end users to perform text searches and retrievals
•The ability of computer applications to identify key words and phrases found in textual data has improved the ability to retrieve key pieces of information from the record
System Communications and Networks
•The evolution of widespread networks of healthcare providers called: integrated delivery systems (IDSs) and the initiation of voluntary regional health information organizations (RHIOs) or more extensive health information exchanges (HIE) have added another dimension to the EHR
•By nature, the healthcare industry depends heavily on information
•In order for any exchange to succeed, healthcare professionals must be able to readily communicate and transmit information to many different locations, sometimes across organizational lines
Because of the importance of system communications and networks, IS administrators in healthcare must:
•Manage a number of existing and evolving communications technologies as well as balance the needs and wants of multiple end users.
•This variation in needs requires system administrators to juggle many technologies or to limit technology choices to only a few. •The problem faced by everyone wishing to share information is the lack of standardization.
•However, efforts toward the development of healthcare IS standards have gained momentum.
•Today, a number of standards organizations are working to develop IS standards for healthcare organizations
Transitions in record practices
•There are a number of challenges related to record content and documentation when organizations adopt electronic health records
•Adoption changes health information workflow and processes
•Sharing of records with other organizations either within a healthcare enterprise or outside requires coordination. •Successful adoption has a much higher probability if issues are anticipated and are part of initiation plans
First, healthcare organizations must maintain legal and regulatory compliance:
•Applicable record content and documentation standards addressed in this chapter apply to healthcare settings no matter the record format
•Complete, accurate, and consistent records must be maintained for each patient. •However, new questions are posed as a result of plans for EHR adoption, and policies and procedures must be developed from resulting discussions
For example, decisions need to be made regarding the timely capture and display of information and when documents become part of a record:
•The latter is particularly important regarding “preliminary” reports, document versions, or when documents are received as part of health information exchanges. •Audit trails to indicate the timing of adding and deleting documents may be important in providing evidence for the chronology of clinical decisions.
•Guidelines for the correction and editing of information are important, as are policies in the event of purposeful or inadvertent record deletion.
•A definition of an organization’s legal health record will provide guidance when content questions arise and particularly in release of information or potential liability or lawsuit situations.
What else needs to be addressed in record transitioning?
•Content edit checks, evidence of use of decision support information, criteria to evaluate records for completeness, and other support processes require determination.
•Role-based guidelines for access to records, including security measures, must be in place.
•Guidelines for retention of records, determination of backup systems, and procedures for eventual record destruction must be addressed
Example of an Electronic Health Record
•The United States Veterans Health Administration’s (VHA) electronic health record is often used as an example of a comprehensive nationwide system.
•The VHA currently encompasses 153 medical centers, over 800 community-based outpatient clinics, 135 nursing homes (which it refers to as community living centers), and 48 domiciliaries (group homes) across the United States
•To be successful, the electronic record system had to capture and exchange data throughout the organization, as well as with other government entities.
•In order for the VHA system to be all things to everyone, flexibility and portability had to be key characteristics
The developers of this EHR focused on the VHA’s three main missions:
•Patient care, research, and education.
•In the area of patient care, the EHR system fosters coordinated care among providers at different locations, improves the legibility of records, and enhances the timeliness of information access.
•In support of research activities, the EHR system offers standardized data sets or databases and improved data accuracy. •Finally, the EHR system enhances the VHA’s educational programs by increasing communication among staff, residents, and interns.
•It also enables the use of decision support tools and enhances the efficiency of clinical management
In addition to scheduling, pharmacy management, and specific medical registries, the Health Care Provider component of VistA includes software addressing each of the following:
Problem list
Health summary
Medical, mental health, nursing, and nutrition services
Vital signs and measurements
Intake and output
Clinical procedures
Remote order entry
Audiology and speech assessments and recording
Social work
Mental health
Laboratory including pathology and blood bank
Radiology and nuclear medicine
Women’s health
Home-based care
Clinical reminders
Adverse reaction tracking
Care management