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

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Health Information Policy & Procedure Checklist


The following list provides an example of the types of policy and procedures that may be included in a manual for health information services. The titles and content of the policy and procedures may vary by facility or corporation. Some of the policy and procedures are listed more than once for cross-referencing purposes.  The policies and procedures should reflect the Health Insurance Portability and Accountability Act (HIPAA), requirements of the electronic health record as well as any state regulations and legal requirements. The (*) will denote areas where it is suggested the policy and procedure include HIPAA and electronic records requirements. The (**) will identify electronic record requirements.



Access, to Automated/Computerized Records*

Access to Records (Release of Information) by Resident and by Staff*

Admission/Discharge Register**

Admission Procedures

  • Facility Procedures – Establishing/Closing the Record**
  • Preparing the Medical Record**
  • Preparing the Master Patient Index **
  • Re-Admission – Continued Use of Previous Record**
  • Re-Admission – New Record**

Amendment of Clinical Records**

Audit Schedule**

Audit and Monitoring System**

  • Audit/Monitoring Schedule
  • Admission/Readmission Audit
  • Concurrent Audit
  • Discharge Audit
  • Specialized Audits (examples)
  • Change in Condition
  • MDS
  • Nursing Assistant Flow Sheet
  • Psychotropic Drug Documentation
  • Pressure Sore
  • Restrictive Device/Restraint
  • Therapy

Certification, Medicare

Chart Removal and Chart Locator Log, Tracking of access to the electronic record/audits.**

Clinical Records, Definition of Legal Electronic Health Records, Designated Record Set and Health Information/Record Service*

Electronic Health Record (e HR) Planning, Training, Implementation and Quality Assurance process* (sample tools).

General Policies

  • Access to Records*
  • Automation of Records (See also computerization)**
  • Availability**
  • Change in Ownership**
  • Completion of Records**
  • Confidentiality**
  • Indexes**
  • Ownership of Records
  • Permanent and Capable of Being Photocopied and/or ability to provide a chronological clinical record.**
  • Retention**
  • Storage of Records Manual Onsite, Automated Record Storage including Hosting**
  • Subpoena
  • Unit Record**

Purpose/General Instructions for Keeping Clinical records, Completing and Correcting Records**

Willful Falsification/Willful Omission**

Closing the Record**

Coding and Indexing, Disease Index**

Committee Minutes Guidelines

Computerization and Security of Automated Data/Records**

Confidentiality – See Release of Information**

Consulting Services for Clinical Records and Plan of Service**

Content, Record (the list provided is not all inclusive and should be tailored to the facility/corporation). If an electronic health record is used, include a description of system items related to the below and the content requirements – any special instructions for automated portions of the record, standards, requirements.

  • General
  • Advanced Directives
  • Transfer Form/Discharge Plan of Care
  • Discharge Against Medical Advice
  • Physician Consultant Reports
  • Medicare Certification/Recertification
  • Physician Orders/Telephone Orders
  • Physician Services Guidelines and Progress Notes
  • Physician History and Physical Exam
  • Discharge Summary
  • Interdisciplinary Progress Notes

Continuity of Business Plan**

Copying/Release of Records – General**

Correcting Clinical Records**

Data Collection/Monitoring**

Definition of Clinical Records/Health Information Service*

Delinquent Physician Visit and e HR monitoring of visits.**

Denial Letters, Medicare

Destruction of Records, Log, Manual or electronic**

Disaster Planning for Health Information**

Discharge Procedures (Including the hybrid record)**

  • Assembly of Discharge Record**
  • Chart Order on Discharge**
  • Completing and Master Patient Index**
  • Discharge Chart Audit**
  • Notification of Deficiencies**
  • Incomplete Record File**
  • Closure of Incomplete Clinical Record**

Emergency Disaster Evacuation**

Establishing/Closing Record**

Falsification of Records, Willful**

Fax/Facsimile, Faxing**

Filing Order, Discharge (Chart Order)**

Filing Order, Inhouse (Chart Order)**

Filing System

Filing System, Unit Record**

Forms Management

Forms, Release of Information*

Forms, Subpoena*

Guide to the location of data in the health record **

Guide to Location of Items in the Health Information Department (Including the e HR)**

Guidelines, Committee Minutes

Hybrid Record

Incomplete Record **


  • ICD Disease Data and reporting**
  • Master Patient Index**
  • Release of Information Index/Log*

Inservice Training Minutes/Record

Job Description:

  • Health Information Coordinator**
  • Health Unit Coordinator**
  • Other Health Information Staff (if applicable)**

Late Entries**

Lost Record – Reconstruction

Master Patient Index**

Medicare Documentation

  • Certification and Recertification
  • Medicare Denial Procedure and Letter
  • Medicare Log**

Numbering System**

Ombudsman, Review/Access to Records**

Omission, Willful**

Order of Filing, Discharge**

Order of Filing, Inhouse**

Organizational Chart for Health Information Department

Orientation/Training of Health Information Department


Physician Visit Schedule, Letters, and Monitoring**

Physician Visits, Delinquent Visit Follow-up**

Quality Assurance Performance Improvement**

  • Defining the Quality Assurance Process/monitoring**
  • Health Information participation
  • QA Studies and Reporting

Readmission – Hybrid Record**

Recertification, or Certification (Medicare)

Reconstruction of Lost Record**

Refusal of Treatment

Release of Information*

  • Confidentiality*
  • Confidentiality Statement by Staff*
  • Copying/Release of Records – General*
  • Faxing Medical Information*
  • Procedure for Release – Sample Letters and Authorizations*
  • Redisclosure of Clinical Information*
  • Resident Access to Records *
  • Retrieval of Records (sign-out system)
  • Subpoena*
  • Witnessing Legal Documents

Reports - generating**

Reports - topics**

Requesting Information*

  • From Hospitals and Other Health Care Providers*
  • Request for Information Process/Form*

Retention of Records and Destruction after Retention Period

  • Example Statement for Destruction**
  • Retention Guidelines**

Retrieval of Records*

Security of Automated Data/Electronic Medical Records*

  • General Procedures*
  • Back-up Procedures*
  • Passwords*

Sign-out Logs

Storage of Records, Manual Onsite and Offsite, Automated Record Storage including Hosting**, *

Telephone Orders**


  • In house Records
  • Maintaining Overflow Record

Unit Record System



AHIS Resident Record Manual; Life Care Medical Record Manual; Kelli Marsh, RHIA – Clinical Record Policy and Procedures Manual

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