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

Introduction

Contents

Purpose And Use of These Guidelines

The long term care (LTC) community requires complete and accurate clinical records and documentation.

Documentation-based survey initiatives, quality indicators, quality measures, corporate compliance,

reimbursement changes and litigation have all had an impact on the industry and the need for properly

maintained clinical record systems. The LTC Health Information Practice and Documentation Guidelines

were developed to provide a resource to health information professionals and healthcare organizations on

the role of the health information practitioners, practice guidelines for establishing and maintaining health

information systems, and documentation guidelines specific to long term care.

Federal regulations for nursing facilities and skilled nursing facilities require organizations to maintain

their clinical records in accordance with accepted professional standards and practices and to employ or

contract with professionals necessary to carry out the regulations.

Just as the LTC industry has seen changes, it is anticipated that these practice guidelines will also be

reviewed, revised and updated to adapt to future changes in practice, systems, and regulations.

Note: These guidelines were developed to address federal regulations for LTC facilities. State regulations

should be followed if they differ from the practice guidelines.

Transition From Medical Records To Health Information Management (HIM)

The terms health information and health information management are used throughout this document to

represent the medical record and medical record department. In the early 1990’s the American Medical

Record Association changed its name to the American Health Information Management Association to

better reflect the role the medical record professional. The new terminology recognized the maintenance

of clinical information in a variety of formats and the evolution of the role of a medical record director to

one whose role is to manage health information beyond the medical record.

Definition of Long Term Care Facility

The term long term care (LTC) facility is used throughout the guidelines to represent nursing facilities and skilled nursing facilities. The term resident was used rather than patient to provide consistency with the term used in the federal requirements for long term care facilities.

Acknowledgements

These guidelines have been developed and made available to health care organizations and health information management professionals through donations to the Foundation of Research and Education in Health Information Management (FORE) by six contributing organizations. In addition to AHIMA, special thanks to --

• Beverly Enterprises
• Extendicare Health Service
• Genesis Health Ventures
• Good Samaritan Society
• Harborside Healthcare Corporation
• HCR-ManorCare

These guidelines were developed by a taskforce comprised of health information management professionals and specialists with key areas of expertise. Their hard work, dedication, experience and insight were instrumental in creating the LTC Health Information Practice and Documentation Guidelines.

LTC Taskforce Members:

Rhonda Anderson, RHIA, Anderson Health Information Systems, Inc.
Monica Baggio Tormey, RHIA, Corporate Medical Record Consultant, Harborside Healthcare Corporation
Dorothy "Dot" Chapman, RHIA, Health Information Management Consultant, Good Samaritan Society
Joy Howe-Spoto, RN, Director of Clinical Risk Management, Beverly Enterprises
Debbie Johnson, RHIT, AHIMA LTC Section, HIM Consultant, D.A. Johnson Consulting
Carmilla "Kelli" Marsh, RHIA, Vice President of Support Services, Westhaven Services Co.
Judy Moffett, RN, Manager of Automated Clinical Systems, HCR ManorCare
Cheryl Olson, RHIA, Director of Health Information Management, Life Care Centers of America
Sharon Schott, RN, Litigation Support Services National Director, Extendicare Health Services, Inc.
Renae Spohn, RHIA, CPHQ, Quality Improvement Department Director, Good Samaritan Society

LTC Taskforce Coordinator and Project Manager:

Michelle Dougherty, RHIA, HIM Practice Manager, AHIMA

Special thanks to those who reviewed and commented on the LTC Health Information Practice and Documentation Guidelines. The comments received were invaluable in validating and improving the quality of this document.

Copyright And Use Of Report

Copyright 2001. All rights reserved. No part of this report may be reproduced, stored in a retrievable system, or transmitted, in any form or by any means electronic, mechanical photocopying, recording, or otherwise. A non-exclusive limited use license is available for healthcare organizations engaged directly in the provision of patient/resident services for use by such organizations for non-commercial non-profit purposes. Any other use requires the written permission of the copyright owner. (Contact AHIMA for written permission. To obtain copyright permission send an e-mail to publications@ahima.org)

These guidelines were developed and made available free of charge via the Internet and AHIMA’s website for use by health care provider organizations and health information management professionals to provide assistance and direction in developing and maintaining health information systems that meet professional practice standards. The guidelines, samples, and examples can be used in development of facility/organization systems, policies and procedures without obtaining special copyright permission.

Reference to HIM Practice Standards

In section four of this report (Practice Guidelines for LTC Health Information and Record Systems) there are HIM Standards in a box which relate to the section topic. These standards were obtained from the book Health Information Management Practice Standards: Tools for Assessing Your Organization published by AHIMA in 1998. Not all HIM standards published in this book were referenced in this report -- only those relevant to LTC.

Example:

Assigning a Medical Record Number

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