AHIMA's Long-Term Care Health Information Practice & Documentation Guidelines  

Please note: Portions of these guidelines are under revision to reflect regulatory and practice changes.

INTRODUCTION

• Purpose and Use of These Guidelines
• Transition from Medical Records to Health Information (HIM)
• Definition of Long Term Care Facility
• Acknowledgements
• Copyright and Use of Report
• Reference to HIM Practice Standards

 
ROLE OF HEALTH INFORMATION STAFF IN LONG TERM CARE FACILITIES

• Job Qualification, Responsibilities, and Functions of Health Information Staff in a LTC Facility  
• Role of the Credentialed Consultant
• Role of the Credentialed Practitioner Working in a Long Term Care Facility
• Role of the Non-Credentialed Practitioner Working in a Long Term Care Facility
• Role of the Health Unit Coordinator
• Evolving Role of Health Information
• Health Information Department Staffing

 
HEALTH INFORMATION CONSULTANT SERVICES

• Frequency of Consultant Visits
• Performance Expectations for a Consultant
• Consultation Reports
• Timeliness of Consultation Reports
• Content of Consultation Reports
• Distribution of Consultation Reports
• Retention (Facility and Consultant)
• Evaluating Consulting Services

 
PRACTICE GUIDELINES FOR LTC HEALTH INFORMATION AND RECORD SYSTEMS

• Record Systems, Organization and Maintenance  
• Maintaining a Unit Record
• Assigning a Medical Record Number
• Maintaining Records in a Continuum of Care
• Defining What is Part of the Medical Record
• Maintenance of the Chart
• Identification/Name and Medical Record Number on Pages
• Common Chart Forms and Thinning Guidelines
• Integrating Hospital Records into the Long Term Care Record
• Thinning the Medical Record
• Maintaining the Overflow Record of Thinned Documents
• Maintaining a "Soft Chart" or "Shadow Record" and Other Types of Records
• Forms Control Processes
• Audits and Quality Monitoring  
• Qualitative vs. Quantitative Audits and Monitoring
• Assessing the Quality of Documentation
• Routine Audits/Monitoring (Criteria and Timeframes)
• Focus Audits and Monitoring Systems
• Integrating Audits/Monitoring into the QA/QI Program
• Retention of Audits, Checklists, and Monitoring Record
• Auditing the Electronic Health Record
• Discharge Record Processing  
• Discharge Record Assembly
• Discharge Record Analysis
• Timely Completion of a Discharge Record
• Incomplete and Delinquent Records
• Maintaining a Control Log for Discharge Records
• When to Close a Record on Temporary Absence
• Closing Records with a Change in Level of Care
• Closing Records with a Payer Change
• Filing and Retrieval  
• Separate Location for Incomplete Records
• Typical Filing Systems
• After Hours Retrieval
• Storage Systems  
• Storage System Options
• Security Issues: Locking Office and Storage Areas
• Alternative Storage Areas
• Retention  
• Retention Guidelines
• Destruction  
• Acceptable Methods of Destruction
• Abstracting Documents Prior to Discharge
• Destruction Logs and Witnesses
• Physical Security of Manual or Paper Records  
• Maintaining a Record Checkout System
• What To Do If a Record Is Lost, Destroyed or Stolen
• Disaster Plans
• Confidentiality and Release of Information   REV 2/2015
• Identification of Confidential vs. Non-Confidential Information
• Resident Access to Their Records
• Confidentiality, Training and Agreements with Employees and Volunteers
• Resident Identification Boards at Nursing Stations
• Maintaining an Access/Disclosure Grid for Employees, Contractors and Outside Parties
• Handling a Request for Medical Records
• Review of Authorization for Release of Information
• Preparing a Record for Release
• Turn Around Time for Responding to a Request for Copies of Medical Records
• Copy Fees for Release of Information
• Documenting the Release of Information (Accounting of Disclosures)
• Redisclosure of Health information
• Redisclosure Upon Transfer to Another Healthcare Facility
• Handling Telephone Requests for Information
• Transmitting Patient Information Via Facsimile
• Responding to a Subpoena or Court Order
• Removing Original Records from the Facility
• Notice of Information Practices
• Designation of a Privacy Officer
• Coding and Reimbursement  
• Training and Resources
• Frequency of ICD-9-CM Coding
• Coding and Billing Relationships
• Investigation of Claim Rejection/Denials Due to Coding
• Coding Issues Under Consolidated Billing
• Indexes and Registries   REV 2/2015
• Master Patient Index
• Maintaining an MPI
• Minimum Content
• Admission/Discharge Register
• Disease Index
• Minimum Statistical Reporting
• Total Admissions
• Total Discharges
• Average Daily Census
• Total Census Days
• Length of Stay
• Percentage of Occupancy

LEGAL DOCUMENTATION STANDARDS

•  Purpose and Definition of the Legal Medical Record
• Legal Documentation Standards
• Defining Who May Document in the Medical Record
• Linking Each Entry to the Patient
• Date and Time on Entries
• Timeliness of Entries
• Pre-dating and Back-dating
• Authentication of Entries and Methods of Authentication
• Signature
• Countersignatures
• Initials
• Fax Signatures
• Electronic/Digital Signatures
• Rubber Stamp Signatures
• Authenticating Documents with Multiple Sections or Completed by Multiple Individuals
• Signature Legends
• Permanency of Entries
• Printers
• Fax Copies
• Photo Copies
• Carbon Copy Paper (NCR)
• Use of Labels in the Medical Record
• Specificity
• Objectivity
• Completeness
• Use of Abbreviations
• Legibility
• Continuous Entries
• Completing All Fields
• Continuity of Entries – Avoiding Contradictions
• Condition Changes
• Document Informed Consent
• Admission/Discharge Notes
• Notification or Communications
• Delegation
• Incidents
• Make and Sign Own Entries
• Appropriateness of Entries – Keep Documentation Relevant to Patient Care
• Legal Guidelines for Handling Corrections, Errors, Omissions, and Other Documentation Problems
• Proper Error Correction Procedure
• Handling Omissions in Documentation
• Making a Late Entry
• Entering an Addendum
• Entering a Clarification
• Omissions on Medication, Treatment Records, Graphic and Other Flowsheets
• Documenting Care Provided by a Colleague
• Patient Amendments to their Record

DOCUMENTATION IN THE LONG TERM CARE RECORD 

• Federal Regulations Pertaining to Clinical Records
• Purpose of the Documentation
• Elimination of Duplication/Redundant Information when Evaluating/Implementing a Documentation System

• Documentation Content in a Long Term Care Record 
• Admission Record
• Assessments
• Integrating Assessments with RAI Process
• Types of Assessments and Requirements
• Preadmission Assessment
• Admission Assessment
• Fall Assessment
• Skin Assessment
• Bowel and Bladder Assessment
• Physical Restraint Assessment
• Self-Administration of Medication
• Nutrition Assessment
• Activities/Recreation/Leisure Interest Assessment
• Social Service
• Mental and Psychosocial Functioning
• Restorative/Rehab Nursing Assessment
• Rehabilitation Services
• Resident Assessment Instrument (RAI) – MDS and CAAs 
• Care Plan 
• Timeliness
• Care Conference
• Admission/Interim Care Plan
• Integrating Acute Problems Into the Care Plan
• Timeliness of Completion of Care Plan
• Authenticating Changes to Care Plan
• Narrative Charting and Summaries 
• Admission/Readmission Note
• Content of Narrative Charting
• Monthly Summary Charting
• Integrated vs. Disciplinary Progress Notes
• Medicare Documentation 
• Skilled Nursing/Therapy Charting
• Supporting Documentation for the MDS
• Therapy Treatment Time
• ADL Charting
• Mood and Behavior Documentation
• Hospital Documentation
• Medicare Certification/Recertification
• Rehabilitative Therapy Documentation 
• Physician Documentation 
• Physician Progress Notes
• Dictated Progress Notes
• NP/PA Documentation
• History and Physical
• Other Professional and Consultation Records/Notes
• Documenting Resident Diagnoses
• Supporting Documentation for Diagnoses
• Resolving Diagnoses
•  Final Progress Note/Discharge Note
• Physician Orders
  
• Admission Orders
• Content of an Order
• Physician Order Recaps/Renewals
• Telephone Orders
• Fax Orders
• Standing Order Policies
• Authentication/Obtaining Signatures
• Transcription of Orders and Noting Orders
• Contacting the Physician to Obtain an Order
• Discontinuing an Order When a New Order is Obtained
• Updating/Changing Physician Order Recaps/Renewals After They Have Been Signed
• Processing Physician Orders After Hospitalization "Resume all Previous Orders"
• Verification of Hospital Orders with Attending Physician
• Accepting Orders From a NP/PA
• Accepting Orders from Specialists or Consultants
• Pharmacy Drug Review
  
• Antipsychotic Drug Therapy 
• Dose Reduction Schedules and Documentation
• Medication and Treatment Records 
• Starting new Medication/Treatment Records Upon Readmission/Hospital Return
• Flow Sheets/Flow Records 
• Service Delivery Records
• Other Clinical Flow Records
• Labs and Special Reports 
• Consents, Acknowledgements and Notices 
• Informed Consent for Use of a Restraint
• Consent, Notice and Authorization to Use/Release Clinical Records
• Notice of Bedhold Policy and Readmission
• Notice of Legal Rights and Services
• Notice Before Transfer
• Notice Prior to Change of Room or Roommate
• Advance Directives 
• DNR Order vs. Advance Directives
• Discharge Documentation 
• Discharge Order
• Discharge Note
• Discharge Summary
• Transfer Form
• Physician’s Discharge Summary vs. Discharge Record

CHECKLIST OF HIM POLICY AND PROCEDURES 

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