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

Practice Guidelines for LTC Health Information and Record Systems

Record Systems, Organization and Maintenance - Updated 6/09

1. Maintaining a Unit Record
2. Assigning a Medical Record Number
3. Maintaining Records in a Continuum of Care
4. Defining What is Part of the Medical Record
5. Maintenance of the Chart
6. Identification/Name and Medical Record Number on Pages
7. Common Chart Forms and Thinning Guidelines
1. Integrating Hospital Records into the Long Term Care Record
2. Thinning the Medical Record
8. Maintaining the Overflow Record of Thinned Documents
9. Maintaining a "Soft Chart" or "Shadow Record" and Other Types of Records
10. Forms Control Processes

Audits and Quality Monitoring - Updated 11/08

1. Qualitative vs. Quantitative Audits and Monitoring
2. Assessing the Quality of Documentation
3. Routine Audits/Monitoring (Criteria and Timeframes)
4. Focus Audits and Monitoring Systems
5. Integrating Audits/Monitoring into the QA/QI Program
6. Retention of Audits, Checklists, and Monitoring Record
7. Auditing the Electronic Health Record

Discharge Record Processing - Updated 6/09

1. Discharge Record Assembly
2. Discharge Record Analysis
3. Timely Completion of a Discharge Record
4. Incomplete and Delinquent Records
5. Maintaining a Control Log for Discharge Records
6. When to Close a Record on Temporary Absence
1. Closing Records with a Change in Level of Care
2. Closing Records with a Payer Change

Filing and Retrieval - Updated 6/09

1. Separate Location for Incomplete Records
2. Typical Filing Systems
3. After Hours Retrieval

Storage Systems - Updated 6/09

1. Storage System Options
2. Security Issues: Locking Office and Storage Areas
3. Alternative Storage Areas

Retention - Updated 6/09

1. Retention Guidelines

Destruction - Updated 6/09

1. Acceptable Methods of Destruction
2. Abstracting Documents Prior to Discharge
3. Destruction Logs and Witnesses

Physical Security of Manual/Paper Records - Updated 6/09

1. Maintaining a Record Checkout System
2. What To Do If a Record Is Lost, Destroyed or Stolen
3. Disaster Plans

Confidentiality and Release of Information - Updated 6/09

1. Identification of Confidential vs. Non-Confidential Information
2. Resident Access to Their Records
3. Confidentiality, Training and Agreements with Employees and Volunteers
4. Resident Identification Boards at Nursing Stations
5. Maintaining an Access/Disclosure Grid for Employees, Contractors and Outside Parties
6. Handling a Request for Medical Records
1. Review of Authorization for Release of Information
2. Preparing a Record for Release
3. Turn Around Time for Responding to a Request for Copies of Medical Records
4. Copy Fees for Release of Information
5. Documenting the Release of Information (Accounting of Disclosures)
7. Redisclosure of Health information
1. Redisclosure Upon Transfer to Another Healthcare Facility
8. Handling Telephone Requests for Information
9. Transmitting Patient Information Via Facsimile
10. Responding to a Subpoena or Court Order
11. Removing Original Records from the Facility
12. Notice of Information Practices
13. Designation of a Privacy Officer

Coding and Reimbursement - Updated 6/09

1. Training and Resources
2. Frequency of ICD-9-CM Coding
3. Coding and Billing Relationships
4. Investigation of Claim Rejection/Denials Due to Coding
5. Coding Issues Under Consolidated Billing

Indexes and Registries

1. Master Patient Index
1. Maintaining an MPI
2. Minimum Content
2. Admission/Discharge Register
3. Disease Index

Minimum Statistical Reporting

1. Total Admissions
2. Total Discharges
3. Average Daily Census
4. Total Census Days
5. Length of Stay
6. Percentage of Occupancy

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