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ahimaltcguidelines log in help Get a free wiki | Try our free business product Wiki Pages & Files View TOC Page history last edited by Mary Ann Leonard 4 years, 11 months ago 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 Retention Guidelines 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 Admission 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 Disc...