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
- 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
- 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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