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Page history last edited by Mary Ann Leonard 9 years ago

 

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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