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Indexes and Registries

Page history last edited by Mary Ann Leonard 9 years, 3 months ago

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

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Indexes and Registries

 

Contents



 

Indexes or registries provide baseline information in a retrievable format and are fundamental components in managing a facility’s health information. At a minimum, every long term care facility should maintain a master patient index (MPI) and admission and discharge register. The disease index is optional unless required by state law.

 

Master Patient Index (MPI)

 

HIM Standard

The computer-based patient record system is supported by the organization-wide master patient index or other resident identification mediation service that ensures accurate and timely resident identification.

 

The master patient index (MPI) is a valuable reference for basic demographic information and resident activity (i.e. admission and discharge dates) within one source. The MPI is an index maintained separately from the resident’s medical record. It is used to identify that a resident had a stay in the facility, the dates of the stay and other important data in an easily retrievable format (i.e. alphabetically or through name searches).

 

Maintaining an MPI

 

An index can be maintained manually or as part of a computerized system. Because the information in the MPI is important for tracking resident stays in an organization, the MPI should be retained on a permanent basis. Information on the MPI should be updated with changes throughout the residents’ stay, such as hospitalizations, discharges, readmissions, etc. 

 

Most long term care facilities maintain the MPI alphabetically. If the MPI is computerized, facility staff should be able to retrieve the information by resident name and by medical record number.

 

Maintaining a Manual MPI:

There is no required form or format for the MPI. The most common manual format for an MPI is the use of index cards. The index cards are completed on admission and updated with changes throughout the resident’s stay. The index cards are typically filed alphabetically in long term care facilities.

Another common method for maintaining a MPI is to use a copy of the admission record (face sheet). On admission the face sheet is printed, kept updated throughout the residents’ stay and on discharge, the discharge date and disposition are documented. The face sheets are maintained alphabetically and retained on a permanent basis.

 

There are a variety of methods for filing the MPI information including separating the current admissions from the discharges or integrating the current admissions with previous discharges. For facilities that have decades of MPI information, it may be necessary to separate some of the MPI cards. For example, to manage the volume of information MPI cards from the 1960’s, 1970’s, 1980’s may be separated, maintained alphabetically and filed together.  Frequently the current residents MPI information cards are maintained separately from the discharged residents information.  This facilitates ease of access of current resident information.

 

Maintaining a Computerized MPI:

Many computer systems have the MPI information readily available through the demographic and census program. It is not necessary to have a manual index if the information is computerized, however, it is critical that the information be available on a permanent basis. There are MPI programs available for other health care settings, but they are not commonly used in the long term care setting at this time unless the facility is attached to a hospital or part of an integrated delivery system.

 

Computerized MPI information has many advantages for an organization including ease in access and retrieval. Because of current limitations in software programs available in the long term care industry, consider the following before moving to a fully computerized MPI:

 

  • Does your system have the capability to retain the core MPI elements on a permanent basis? If not, a manual system should be considered to back up the computerized system.
  • If you change computer systems, how will you access the MPI information in the old system? Will the new system allow for transfer of the core MPI elements from the previous software? If not, the MPI information from the previous system should be printed out and maintained manually or data entered into the new system. 

 

Some computer systems may will have a report that allows for an MPI card or sheet to be printed. The most common reasons for printing a hard copy include:

  • Continuation of a manual system. Many facilities have decades of MPI information available in a manual format and see advantages to continuing this type of system particularly as a back up to the computerized system.
  • If resident and MPI information has to be purged from the computer system because of memory/storage limitations the MPI information should be maintained manually.
  • Manual systems are maintained when there are questions about the long term viability of the computer system and concerns that the system won’t be available for retrieval of information.

It is possible to maintain a partially automated and partially manual MPI system. There should be a clear point in time when all MPI information is maintained in the computer system rather than manually. Proper safeguards must be in place to prevent from loss or destruction of the computerized MPI information.

 

Retention:

The MPI should be retained on a permanent basis to provide historical access to basic resident information and dates of stay in an organization.

 

Minimum Content

 

The content or format of the MPI may vary from health care facility. At a minimum, the MPI in a long term care facility should contain the following data elements:

  • Medical record number
  • References to additional assigned medical record numbers 
  • Resident name (legal name including surname, given name, middle name or initial, name suffixes (Junior, IV), and prefixes (Father, Doctor).
  • Date of Birth (day, month, and year)
  • Gender
  • Address
  • Alias or previous name (other names patient is known including nicknames, maiden name, previous name that was legally changed)
  • Social security number
  • Admission/Readmission date(s)
  • Discharge/Transfer date(s)
  • Resident disposition (resident’s intended care setting following discharge or died)

There are many other data elements such as attending physician, marital status, emergency contact that can be included in a facility MPI. The This list provides the minimum content, but should not be considered all-inclusive. Other data elements should be added to meet the needs of the facility/organization. AHIMA has published a practice brief with additional core elements to the MPI. This practice brief is at www.bok.ahima.org available onlineProvide a link?

 

Admission/Discharge Register

 

An admission and discharge register (or census register) lists chronologically all admissions and discharges by date. This type of register can be maintained either manually or on a computer system. Some states require a specific format such as a bound book which continues to be the most common format used for this type of register.  Look into this

If there are multiple care settings on a long term care campus (i.e. assisted living and a long term care facility –NF/SNF), admission and discharge information should be maintained for each setting. The campus must determine if one census register will be maintained for the campus or if each setting will maintain their own register. If one is maintained, the register must clearly indicate the care setting.

 

Minimum Content:

At a minimum, the admission/discharge register should contain the following information:

Admissions:

    • Admission date
    • Resident name
    • Medical record number
    • Where admitted from

Discharges:

    • Discharge date
    • Resident name
    • Medical record number
    • Where discharged to/discharge disposition

  Optional Information:

    • Transfer and return dates (bedhold information)
    • Pay source (on admission and on discharge)
    • Discharge length of stay
    • Attending physician

 

Some state agencies may require additional information, such as date of birth, included in the report when provided to them.  If this information is required, it is beneficial to include it in the ongoing register format.

 

Register Format:

Unless required by state law, facilities can determine the format and content of the admission/discharge register to meet their needs. This type of register can be very helpful in compiling statistical information/reports for a facility.  Some computer systems may provide this information as a report.

 

The following are two examples of the most common formats used for recording admission and discharge activity:

  • For each month, admissions are recorded on one page/side of the register and discharges on the opposing page. Both the admissions and discharges are listed chronologically.
  • For each month, list chronologically all activity integrating admissions and discharges and sequencing them in date and time order. This method gives you a picture of the activity each day whether it was an admission or a discharge.

 

Retention:
The admission/discharge register should be retained on a permanent basis to provide a historical record of activity in the long term care facility.

 

Disease Index

 

HIM Standard:

 

  • The integrity of a disease index is maintained.
  • Disease indexes are used to provide cross-reference for locating health records of all patient types for the purposes of epidemiological and biomedical studies; health services research; and statistical research on occurrence rates, ages, sex, complications, and associated conditions; as well as continuous quality improvement/total quality management activities.
  • The maintenance of a disease index may be required by state regulation. In the absence of such a requirement, the maintenance of a disease index is optional for long term care facilities. The decision to maintain a disease index should be based on facility/corporate need for diagnostic information. Disease or diagnosis information can be a valuable tool in understanding the population served by the facility, for evaluating special programs offered, or to assist with planning for the future programs such as an Alzheimer's or rehab unit. If a long term care facility decides to maintain a disease index, either a manual or computerized format can be used to provide access to diagnostic information on the resident population.

 

Content:

The most common purpose for a disease index in a long term care facility is to identify or provide access to resident(s) information who have a certain disease/diagnosis based on an ICD-9-CM the appropriate ICD diagnosis code.

 

At a minimum, a disease index report should include:

  • Resident’s name
  • medical record number
  • Attending physician
  • Admission date
  • Discharge date
  • Discharge length of stay
  • ICD-9-CM/ICD-10-CM diagnosis codes present during the resident’s stay. (For reporting or planning purposes, it can be helpful to identify the primary diagnosis for which treatment was received.)

 

Optional Information:

  • Resident’s age or date of birth
  • Resident’s gender sex

 

Format:

There is not a specific format required for a disease index unless dictated by state law. Either a manual or computerized index can be maintained. Forms supplies for the long term care industry have sample forms that can be used for maintaining the disease index.

 

Since disease indexes have primarily been maintaineding manually, the availability of reports through the clinical information system have been overlooked as a means for maintaining the index. If a clinical information system collects diagnostic information and provides reporting capabilities by resident and by diagnosis code the system may have the capability of serving as a disease index. The advantages of using a computerized system is that diagnoses are updated continually through a residents stay minimizing the need to additional staff time in maintaining the index.

 

If using an automated system, the software should have the capability to report diagnoses for discharged residents as well as current residents. To get access to disease index information, the system should have the capability of searching the resident database by diagnosis code (i.e. 428.x) and by a range of diagnosis codes (801 – 899). The system should be able to identify the specific resident(s) who has been assigned the code (s) queried with a specific date range identified.

 

Retention:

Unless otherwise specified by state law, the recommended retention period for a disease index is 10 years.  For those states where the clinical record retention schedule is less than 10 years, it is recommended the index be maintained in hard copy or pdfa format.


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