2. ROLE OF THE HEALTH INFORMATION STAFF IN LONG TERM CARE FACILITIES:

In order to maintain quality health information systems, proper staffing and allocation of resources is necessary. The following guidelines provide an outline on the recommended qualifications, responsibilities and functions that would be performed by four different types of positions – 1) a health information consultant, 2) a credentialed health information practitioner working in a facility, 3) a non-credentialed practitioner working in a facility, 4) and a health unit coordinator. As documentation and clinical record systems increase in complexity in response to changes in the industry, HIM professionals and staff provide valuable expertise and help to maintain health information systems that impact quality of care, regulatory, legal, compliance and financial issues.

2.1.1 Role Of The Credentialed Consultant:

Many long term care facilities have access to a Health Information Consultant to provide professional expertise on health information, documentation and medical record issues. Consultants are usually contracted independent of the organization to support non-credentialed staff employed at the corporate level. Consultants may also serve as an additional resource to a HIM corporate consultant to assist with state-specific issues, assist with implementation of corporate policies, and procedures. Consultants may also be used for special projects, independent auditing/monitoring services, training, etc. even when a credentialed practitioner is employed by the facility.

QUALIFICATIONS OF A CONSULTANT:

The following qualifications are recommended for a consultant in long term care.

• Credentialed as a Registered Health Information Administrator (RHIA) or a Registered Health Information Technician (RHIT). Note: A RHIA (previously a RRA) holds a 4 year bachelor degree. A RHIT (previously an ART) typically has a 2 year associate degree or technical training.
• Experience in long term care preferably as a Director or Coordinator of Health Information Services.
• Knowledge of regulations, survey process, accreditation standards and professional standards of practice pertaining to SNF/NF.
• Understanding of payment systems for SNF/NF including Medicare and Medicaid.
• Knowledge and application of ICD-9-CM coding in long term care.
• Understanding of HCPCS and CPT coding systems.
• Knowledge of documentation and legal issues pertaining to health information.
• Knowledge of quality assurance and ability to apply a quality improvement process to problem solving.
• Superior presentation skills, both oral and written.
• Solid clinical understanding of anatomy, physiology, pathophysiology and clinical/nursing process.
• Ability to teach using a variety of methods.
• Computer skills and understanding of information systems used on long term care with the ability to assist a facility move toward an electronic medical record.
• Supervisory and management skills and experience.
• Organizational skills.

Personal attributes of a qualified consultant should include:

• Ability to perform critical thinking, analysis, and problem solving.
• Leadership abilities preferred with an understanding of how to function within a team.
• Flexibility, creativity, and adaptability in dealing with problems and facility/corporate staff.
• Good communication skills with the ability to provide constructive information while being sensitive to the customer's needs.

REPORTING:

The Health Information Consultant should report to the Administrator or Executive Director of the organization to assure that he/she is aware of findings and recommendations that affect the facility operation and risk factors. The Administrator may choose to delegate direct reporting during a visit to another staff member such as the Director of Nursing Services or the Coordinator of Health Information Services.

COMMON FUNCTIONS PERFORMED BY A HEALTH INFORMATION CONSULTANT:

A consultant should be able to perform and train on all of the functions of a Health Information Coordinator as well as many of the functions of the Health Unit Coordinator. The following functions are unique to the role of a consultant.

• Ability to provide assistance and function as a key resource for the development, transition, and maintenance of an electronic medical record.
• Assist with implementation and function as a key resource on the Health Insurance Portability and Accountability Act (HIPAA) including information system security issues and privacy.
• Provide expertise on compliance issues and the integration of clinical documentation and coding with the billing process.
• Develop, implement and monitor health information department policy and procedures and job descriptions. Make recommendations or assist with implementation of corporate policies.
• Provide training and orientation to health information personnel on functions of the department and facility staff on documentation.
• Develop and maintain health information systems and processes that meet regulatory requirements (both state and federal), professional practice standards, legal standards, and management/corporate policy.
• Establish a process for systematically reviewing documentation on an ongoing basis for both quality and quantity of documentation.
• Ability to complete documentation/medical record audits and monitoring with an ability to assess the quality of documentation.
• Ability to recommend corrective actions for findings on medical record audits/monitoring.
• Initiate clinical record systems and indexes.
• Assist with forms development and forms analysis/flow.
• Support compliance process of facility/organization.
• Support quality assurance/quality improvement process of the facility/organization.
• Train staff on quality assurance/quality improvement process related to health information management and appropriate methods for the collection of data.
• Provide resources to the facility on health information, documentation, regulations, standards of practice, etc.
• Develop consultation reports in a timely manner. Communicate findings and recommendations effectively to facility administration and interdisciplinary team members.
• Maintain good communication with facility staff and interdisciplinary team members. Empower facility staff to work independently.

QUALIFICATIONS OF A CREDENTIALED PRACTITIONER:

A growing trend in the industry is to hire credentialed practitioners to manage the health information department in a facility. Facilities who hire a credentialed practitioner often fore-go contracting with a consultant or they will utilize a consultant for independent audit and training services. The following list provides the recommended qualifications for a credentialed practitioner working in long term care. If you are hiring a practitioner new to long term care, additional training specific to long term care regulations and documentation will be needed.

• Credentialed as a Registered Health Information Administrator (RHIA) or a Registered Health Information Technician (RHIT). Note: A RHIA (previously a RRA) holds a 4 year bachelor degree. A RHIT (previously an ART) typically has a 2 year associate degree or technical training.
• Experience in long term care preferred.
• Knowledge of regulations, survey process, accreditation standards and professional standards of practice related to long term care.
• Understanding of payment systems including Medicare and Medicaid.
• Knowledge and application of ICD-9-CM coding appropriate for LTC.
• Understanding of HCPCS and CPT coding systems.
• Knowledge of documentation and legal issues pertaining to health information.
• Computer skills and understanding of information systems used in long term care.
• Supervisory and management skills and experience preferred.
• Basic understanding of the budget and monitoring process.
• Planning and organizational skills.

Personal attributes of a credentialed health information practitioner should include:

• Leadership abilities preferred with an understanding of how to function within a team.
• Ability to provide instruction or guidance and communicate effectively.
• Ability to perform critical thinking, analysis, and problem solving.
• Flexibility, creativity, and adaptability in dealing with problems and staff.
• Good customer service and telephone skills.
  

REPORTING:

It is recommended that this position report directly to the Administrator or Executive Director in a facility. There are a number of reasons why reporting to the Administrator is important for this position. First, the medical record is a multidisciplinary record. Overall decisions made about the record, use of data and analysis should not be influenced by one discipline over another. Second and most important, full disclosure of audit and quality monitoring findings should be reported to the facility administrator and the quality assurance committee. Many of the functions, data gathering and analysis directly influence administrative and clinical management of the facility.

COMMON FUNCTIONS PERFORMED BY A CREDENTIALED HEALTH INFORMATION PRACTITIONER:

The following functions are recommended for a credentialed health information practitioner and represent the core functions for health information. Facility size, admission and discharge rates, department staffing and other non-HIM responsibilities assigned to the position should all be considered when developing the final job description for a facility. In a facility that also employs health unit coordinators, some of the functions outlined may be managed by this position but performed by the health unit coordinator.

Supervisory/Management Functions:

• Maintain current policy and procedures and job descriptions for the health information department.
• Manage human resource functions for the department including interviewing, hiring, staff scheduling, performance evaluation, disciplinary actions, and termination.
• Supervise health information staff to assure staff competency and performance.
• Provide guidance, motivation and support to health information staff.
• Monitor department budget as directed.
• Serve as the Privacy Officer under HIPAA and may serve as the Security Officer depending on expertise and facility need.

Quality Monitoring and Quality Assurance Functions:

• Participate in the facility quality assurance committee and process. Optional: Coordinate the facility quality assurance program.
• Maintain a qualitative and quantitative audit/quality monitoring process. Collect and report data from audit findings to QA committee. Report, monitor and follow-up on problems/concerns. Maintain routine audit and monitoring systems (admission, MDS, concurrent, acute problem, discharge) and focus audits on problem areas, QA concerns, Quality Indicator and survey issues.

Health Information Management Functions:

• Maintain security of health information systems and medical records. Assure physical protection is in place to prevent loss, destruction and unauthorized use of both manual and electronic records. For example, assure safeguards are in place such as record sign-out systems, assignment of computer passwords/log-ons, and systems for securing file cabinets and file rooms where overflow and discharge records are stored.
• Assure systems are in place to maintain confidentiality of both manual and electronic health information.
• Manage the release of information functions for the facility including review and processing of all requests for information. Maintain facility policies and standards of practice to assure release of information requests are appropriate and meet legal standards.
• Maintain a forms management system for development, review, and reproduction of facility forms. Maintain a master forms manual.
• Maintain systems for filing, retention and destruction of overflow/thinned records and discharge records.
• Develop systems for retention and destruction of medical records stored in an electronic format.
• Complete facility statistical reports such as monthly facility statistics, daily census, and licensure reports as applicable.
• Participate in meetings and committees such as daily stand-up, administrative/department head, quality assurance/quality improvement, and Medicare documentation review.
• Provide inservice education as applicable on health information issues.
• Provide orientation to new employees on topics such as the medical record organization and content, record completion, confidentiality, documentation standards and error correction procedures.
• Support and assist in carrying out corporate compliance initiatives as assigned by administrator.
• Manage the credentialing process for physicians and other professional staff when applicable.
• Optional: Review MDS validation reports and take appropriate actions to ensure errors are corrected. Retrieve quality indicator reports from HCFA and review findings.

Computerization/Automation:

• Understand all aspects of clinical computer system.
• Participate in decisions related to the computer system including systems selection, planning, and future expansion.
• Provide resources for training on computer system and use of clinical applications.
• Monitor security of the system such as assuring audit trails and password security are in place. Monitor audit trails and follow up with possible breaches in confidentiality/security.
• Assure ICD-9-CM database utilizes the current version.
• Assure systems are in place to maintain up to date resident-specific information in the clinical information system.
• Complete data entry functions as applicable.
• Optional: Maintain the care plan and MDS schedule and transmit MDS information.

Oversight Records Management Functions:

The following list outlines the records management functions that are the responsibility of the health information department on admission, during the resident’s stay, and upon discharge. Depending on the facility size and department staffing some or all of these functions may be completed by other department staff such as a health unit coordinator.

Admission:

• Complete the appropriate information in the census register.
• Complete and file as applicable the master patient index information (computerized or manual).
• Initiate the inpatient medical record and inhouse overflow file, prepare labels, etc.
• Complete admission checklists and admission audits.
• Complete coding and indexing of admission diagnoses.

During the resident’s stay:

• Conduct concurrent audits/quality monitoring at regular scheduled intervals.
• Code diagnoses at regularly scheduled intervals.
• Thin inhouse records in accordance with the written policy and procedure and file in chart order for discharge in the inhouse overflow file.
• Contact physicians or departments as appropriate when signatures or information is needed before records can be completed.
• Maintain a monitoring system to assure telephone orders and other information is signed or completed by the physician as needed.
• File all incoming clinical information in the inhouse records on a daily basis.
• Monitor timeliness of physician visits on a monthly basis.

Discharge:

• Update discharge information on master patient index (manual or electronic).
• Record appropriate discharge information in the census register.
• Initiate the discharge record control log to monitor discharge record processing status.
• Obtain the discharge clinical record from the nursing station within 24 hours of discharge or death of a resident.
• Assemble record from the nursing station and the overflow file in established discharge order.
• Analyze the record for deficiencies using the discharge record audit/checklist.
• Follow up and monitor discharge record deficiencies including monitoring/mail information to the physician for completion as applicable.
• Maintain discharge record control log.
• File discharge record in incomplete clinical record file until complete and then file the discharge record in the complete file.
• Code and index final diagnoses using the ICD-9-CM code books.

QUALIFICATIONS OF A NON-CREDENTIALED PRACTITIONER:

The qualifications and skills vary widely for a non-credentialed practitioner coordinating the health information functions in a facility. The basic functions of the health information department warrant the following minimum qualifications for an entry-level practitioner:

Minimum Entry Level:

• High school graduate or equivalent.
• Knowledge of medical terminology.
• Basic computer and typing/data entry skills.
• General office skills including filing, organizing, etc.
• Oral and written communication skills.
• Good customer service and telephone skills.
• Ability to work within a team.
• Empathy for the elderly.

Recommended Additional Qualifications:

• Long term care or healthcare experience preferably as a Coordinator of Health Information in another facility.
• Training as a Medical Records Secretary or equivalent.
• Experience with ICD-9-CM coding.
• Knowledge of documentation and legal issues.
• Knowledge of regulations, accreditation standards, and professional standards of practice for health information in long term care.
• Understanding of payment systems in long term care.
• Ability to provide instruction or guidance and communicate effectively.
• Supervisory and management skills depending on size of the department.
• Knowledge of the budget process.
• Interest in maintaining professional development and continuing education on health information issues.

REPORTING:

It is recommended that this position reports the Administrator or Executive Director, however, this may vary depending on the skills and expertise of the individual. If the department is responsible for audit and quality management functions and/or supervises a department reporting to the administrator is imperative.

COMMON FUNCTIONS PERFORMED BY A NON-CREDENTIALED HEALTH INFORMATION PRACTITIONER:

The functions of this position are a subset of those functions outlined in the Credentialed Health Information Practitioner based on training, past experience, and skill level. At a minimum when hiring this position, the non-credentialed practitioner should be able to complete the following functions. The functions in the Credentialed Health Information Practitioner list could be completed by this position (depending on skill and experience) under the direction of a credentialed consultant.

Supervisory/Management Functions:

• Maintain current policy and procedures and job descriptions for the health information department.
• Monitor department budget as directed.

Quality Monitoring and Quality Assurance Functions:

• Participate in the facility quality assurance committee and process. Optional: Coordinate the facility quality assurance program.
• Maintain a quantitative audit/quality monitoring process and qualitative audits. Collect and report data from audit findings to QA committee. Maintain routine audits (admission, MDS, concurrent, acute problem, discharge) and focus audits on problem areas, QA concerns, Quality Indicator and survey issues.

Health Information Management Functions:

• Maintain security of health information systems and medical records. Assure physical protection is in place to prevent loss, destruction and unauthorized use of both manual and electronic records. For example, assure safeguards are in place such as sign-out systems, assignment of computer passwords/log-ons, and systems for securing file cabinets and file rooms where overflow and discharge records are stored.
• Assure systems are in place to maintain confidentiality of both manual and electronic health information.
• Manage the release of information functions for the facility including review and processing of all requests for information. Maintain facility policies and standards of practice to assure release of information requests are appropriate and meet legal standards.
• Maintain a forms management system for development, review, and reproduction of facility forms. Maintain a master forms manual.
• Maintain systems for filing, retention and destruction of overflow records and discharge records.
• Develop systems for retention and destruction of medical records stored in an electronic format under the direction of a consultant.
• Complete facility statistical reports such as monthly facility statistics, daily census, licensure reports as applicable.
• Participate in meetings and committees such as daily stand-up, administrative/department head, quality assurance/quality improvement, Medicare documentation review.
• Support and assist with carrying out corporate compliance initiatives as assigned by administrator.
• Manage the credentialing process for physicians and other professional staff when applicable.

Computerization:

• Understand all aspects of clinical computer system.
• Provide input into decisions related to the computer system including system selection, planning, and future expansion.
• Monitor security of the system such as assuring audit trails and password security are in place. Monitor audit trails and follow-up with possible breaches in confidentiality/security.
• Assure ICD-9-CM database utilizes the current version.
• Assure systems are in place to maintain up to date resident-specific information in the clinical information system.
• Complete data entry functions as applicable.
• Optional: Maintain the care plan and MDS schedule and transmit MDS information.

Records Management Functions:

Admission:

• Complete the appropriate information in the census register.
• Complete and file as applicable the master patient index information (computerized or manual).
• Initiate the inpatient medical record and inhouse overflow file, prepare labels, etc.
• Complete admission checklists and admission audits.
• Complete coding and indexing of admission diagnoses.

During the resident’s stay:

• Conduct concurrent audits/quality monitoring at regular scheduled intervals.
• Code diagnoses at regular scheduled intervals.
• Thin inhouse records in accordance with the written policy and procedure and file in chart order for discharge in the inhouse overflow file.
• Contact physicians or departments as needed when signatures or information is needed before records can be completed.
• Maintain a monitoring system to assure telephone orders and other information is signed or completed by the physician as needed.
• File all incoming clinical information in the inhouse records on a daily basis.
• Monitor timeliness of physician visits on a monthly basis.

Discharge:

• Update discharge information on master patient index (manual or electronic).
• Record appropriate discharge information in the census register.
• Initiate the discharge record control log to monitor discharge record processing status.
• Obtain the discharge clinical record from the nursing station within 24 hours of discharge or death of a resident.
• Assemble record from the nursing station and the overflow file in established discharge order.
• Analyze the record for deficiencies using the discharge record audit/checklist.
• Follow up and monitor discharge record deficiencies including monitoring/mail information to the physician for completion as applicable. Maintain discharge record control log. File discharge record in incomplete clinical record file until complete and then file the discharge record in the complete file.
• Code and index final diagnoses using the ICD-9-CM code books.

2.1.4 ROLE OF THE HEALTH UNIT COORDINATOR (UNIT CLERK/SECRETARY, HEALTH INFORMATION ASSISTANT):

In addition to a health information manager, some facilities may choose to also hire a health unit coordinator(s) depending on facility size, number of admissions and discharges, or resident acuity level. Although this position is typically found at the nursing station, their functions primary revolve around the monitoring and completion of the record and station management. Since many of the health information functions are performed by the health unit coordinator position, it was critical to address this position under a health information model.

QUALIFICATIONS OF A HEALTH UNIT COORDINATOR:

Minimum Entry Level:

• High school graduate or equivalent.
• Knowledge of medical terminology.
• Basic computer and typing/data entry skills.
• General office skills including filing, organizing, scheduling and tracking.
• Oral and written communication skills.
• Good customer service and telephone skills/etiquette. Tact and warmth when dealing with family and residents.
• Ability to work within a team.
• Empathy for the elderly.

Recommended Additional Qualifications:

• Medical office secretary or health unit coordinator training/certificate (or other applicable course).
• Long term care or healthcare experience preferably as a Health Unit Coordinator.
• Knowledge of documentation and legal issues.
• Knowledge of regulations, accreditation standards, and professional standards of practice for health information in long term care.
• Experience with transcribing physician orders with knowledge of medications and applicable terminology.

REPORTING:

It is recommended that the health unit coordinator position report to the Manager of Health Information Services to provide consistent application of health information policies throughout the facility. Because of the unique nature of a health unit coordinator, it is important that this position have an indirect reporting relationship with the nurse manager or supervisor for the nursing station.

COMMON FUNCTIONS PERFORMED BY A HEALTH UNIT COORDINATOR:

When this position is utilized in a facility, many of the record management functions are performed by the health unit coordinator along with additional functions unique to coordinating a nursing station. This position provides assistance to the nursing staff by moving non-nursing clerical functions away from nursing allowing them to spend more time with direct patient care. If a facility does not utilize a health unit coordinator position or incorporate their functions in another position, the nursing staff are completing many clerical functions keeping them away from delivery of direct patient care.

Records Management Functions:

When a health unit coordinator position is utilized by a facility, the following records management functions are performed by this position:

(Do you agree with what I have crossed off for the Health Unit Coordinator position? Other functions were added to the records management lists)

Admission:

• Initiate the inpatient medical record and inhouse overflow file, type labels, etc.
• Coordinate admission process.
• Optional: Transcribe admission orders after review by clinical staff.
• Complete admission checklists.

During the resident’s stay:

• Thin inhouse records in accordance with the written policy and procedure and file in chart order for discharge in the inhouse overflow file.
• Maintain the in-house chart appearance and organization.
• Maintain a monitoring system to assure telephone orders and other information is signed or returned by the physician and other professionals.
• File all incoming clinical information in the inhouse records on a daily basis.
• Monitor timeliness of physician visits on a monthly basis in conjunction with the Manager of Health Information Services. Pull charts for physician rounds and transcribe new orders if applicable.
• Track and schedule routine labs.
• Schedule resident appointments and arrange transportation.
• Transcribe vitals, input/output information, per system.
• Prepare paperwork for transfer or referrals.
• Optional: Transcribe physician orders once obtained from clinical staff. (Clinical staff to sign off on transcription).
• Optional: If data-entry is expected in this position for the MDS or care plan, additional time should be allocated.

Discharge:

• Prepare paperwork for discharge.
• Assemble record from the nursing station and the overflow file in established discharge order.

Nursing Station-Specific Functions:

• Answer telephones at the nursing station.
• Maintain an organized nursing station.
• Stock forms and clerical supplies on the station.
• Maintain station lists.
• Maintain nursing assistant care cards/assignment records.
• Completes station filing of loose reports, policies, etc.

Other Functions:

Additional hours should be allocated to this position if non-health information functions such as staffing and central supply are shared with this position.

2.1.5 EVOLVING ROLE OF HEALTH INFORMATION

As computerization continues to evolve, the role of the HIM practitioner will also change. Although some traditional functions in maintenance of a manual record may be eliminated, new issues will take their place. The HIM role will continue to be responsible for oversight of confidentiality, compliance, privacy and security management programs, ongoing auditing of the electronic medical record, and audit trails. HIM practitioners should be responsible for orientation and ongoing training of clinical staff on the information system, and overall administration of the information system. Even with a computerized record system, many of the routine HIM functions will still need to be carried out.

With the implementation of HIPAA, the HIM practitioner will see new roles as a privacy officer and possibly a security officer. Expertise on code sets will also be necessary for proper coding and reporting under the federal regulation. The HIM role in corporate compliance and billing should also evolve to assure that documentation supports services billed by the facility.

2. HEALTH INFORMATION DEPARTMENT STAFFING

   Staffing the health information department is based on five critical issues:

   • The time requirements for functions under the responsibility of the health information department (see job positions and functions in Sections 2.1.
   • Resident acuity and complexity.
   • Census based on number of residents in the facility.
   • Number of resident exchanges (admission, discharge, hospital transfer and hospital return).
   • Availability of information technology.