Over the past decade, the long term care (LTC) industry has had an increased need for complete and accurate clinical record documentation. Documentation-based survey initiatives, quality indicators, 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.

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.

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

 

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

 

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 c 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.