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LTC Guidelines, Section 4

4. PRACTICE GUIDELINES FOR LTC HEALTH INFORMATION AND RECORD SYSTEMS

RECORD SYSTEMS, ORGANIZATION AND MAINTENANCE:

A medical record must be maintained for every resident in a long term care facility. With varying levels of automation, there may be some records maintained electronically and some in paper format. This section of the report will deal with maintenance of the paper medical record.

It is critical that every facility have formalized systems in place for the maintenance of their records. Records should be systematically organized and readily accessible. The following practice guidelines establish a baseline for the systems that should be in place for maintaining the record systems in a facility.

Maintaining a Unit Record
A unit record and unit numbering system is recommended for long term care facilities. With a unit record, the patient is assigned a medical record number on the first admission which is retained for all subsequent admissions/readmissions. The patient’s entire medical record is thus filed together as a unit under one number (there may be multiple volumes and folders). (Health Information Management, Huffman)

In long term care, the record from previous admissions should be brought forward to be filed with the current admission. All records from previous admissions are pulled forward and usually maintained in the overflow files. It is best to separate the past records for a current admission from the discharge record files so the chart is not inadvertently filed in storage and destroyed.

Bringing previous charts forward will provide the most comprehensive picture of the residents medical history and therapy. The previous records should be readily accessible to staff for use in the assessment and care planning process.

The medical records from previous stays remain in their original file folder and are retained chronologically with other records for patients currently admitted to the facility. The records from one discharge to another are not combined into one folder.

Assigning a Medical Record Number

HIM STANDARD:

The healthcare organization has a policy that requires a separate, unique health record for each resident.

Each resident admitted to the long term care facility should be assigned a unique medical record number. The following are general rules to follow when assigning medical record numbers:

Assign a medical record number only after a resident is admitted. This will prevent numbers from being assigned when the resident is not actually admitted to the facility.
Assign numbers chronologically. Each new admission is assigned the next sequential number.
Exception: For any subsequent admissions, reassign the previous medical record number. You may use a modifier to the medical record number to designate multiple admissions. For example: 1234 – a or 1234 – Always verify in the master patient index that the resident had not been in the facility before.
If a resident was assigned a number, but was not admitted, make a notation in the admission/discharge register that the resident was not admitted.

Maintaining Records in a Continuum of Care:
For healthcare campuses or continuums it is recommended that separate records are kept for each of the different care settings. For example, a separate record is maintained for assisted living, a record for the NF/SNF, a record for home care, etc. However, it is not recommended to create different records for a change in level of care such as from NF to SNF.

When transferring between care settings (i.e. assisted living to SNF), it is recommended that an interdisciplinary transfer form or discharge instructions be completed to assure continuity of care. Include copies of relevant documentation to facilitate the assessment and care planning process.

Health information staff should oversee record management, storage, retention, and destruction for the medical records maintained by the campus to assure that the medical records for each of the care settings are maintained in an organized and systematic filing and retrieval system.

To assist with tracking medical record numbers/campus numbers, admissions, discharges and transfers there should be a campus-wide master patient index maintained or another mechanism to link all records to the resident.
Defining What is Part of the Medical Record
The medical record in a long term care facility reflects the multi-disciplinary approach to assessment, care planning and care delivery. The medical record includes but is not limited to the following type of information: Resident identification, admission/readmission documentation, advance directives and consents, history and physical exams and other related hospital records, assessments, MDS, care plan, physicians orders, physician and professional consult progress notes, nursing documentation/progress notes, medication and treatment records, reports from lab, x-rays and other diagnostic tests, rehabilitation and restorative therapy records, social service documentation, activity documentation, nutrition services documentation, and other miscellaneous records including correspondence and administrative documents.

Facility policy should specifically outline in the format of a chart order the exact documents and records that will be considered part of the medical record. If portions of the record will be retained in an electronic medical record system, policies should differentiate between those records that will be paper-based and those that are electronic.
Maintenance of the Medical Record
It is critical that both the active record and the overflow records are maintained in a systematically organized fashion. This means that all records have an established chart order or order of filing that is followed. All records (records on the nursing station, overflow records, and discharge records) should be readily accessible, maintained in an organized chart order, filed in an easily retrievable manner, and maintained in folders or chart holders sufficient in size for the volume of the record. The chart holders and folders should be kept neat, clean and orderly.

It is recommended that a chart order or order of filing with thinning guidelines be kept in the record and at the nursing station to direct staff to the proper location of forms.
Identification (Name and Number) on pages of the Medical Record
From a legal perspective, each page or individual documents (i.e shingled telephone orders) in the medical record should contain resident identification information. At a minimum, both the resident name and medical record number should be on each form. If labels/label paper is used, resident identification information must be included on the label. The name and number should be placed on both sides of a page because records are frequently copied and both sides may not be included. The name of the form should also be printed on both sides of a two-sided form.

For example, identification information can be written on the page in permanent ink, stamped using an addressograph, or affixed with a label placed. Resident specific information printed from a computer system to be filed in the medical record should include resident identification information on each page.
Common Forms and Thinning Guidelines

HIM STANDARD:
The healthcare organization has a policy that establishes a uniform chart order for health records.

This section outlines the common chart forms found in a long term care record. The titles, location in the record may be different, but the thinning guideline would remain consistent for the type of documentation contained. Thinning the medical record is a process of removing records older than a certain date and moving them into a secondary record known as the overflow record.

The establishment of thinning guidelines is a standard of practice for the long term care industry. Federal regulations require clinical records to include (1) sufficient information to identify the resident; (2) a record of the resident’s assessment; (3) the plan of care and services provided; (4) the results of any pre-admission screening conducted by the State; and (5) progress notes. 42 C.F.R. § 483.75 (l)(5). Check licensure rules to determine if state law delineates a specific thinning guideline.

The goal of the thinning guideline is to retain documentation in the resident’s chart that reflects the current plan of care and services provided. Unless required by state regulations, it is not necessary to keep the original assessment or progress notes in the record. The overflow record should be easily accessible for review of admission documentation.

By listing a form in the following chart order, we are identifying documents commonly found in the medical record. This should not be interpreted as a recommendation or requirement that the form be a mandatory part of the long term care record. See section 6.0 on content of documentation to address the type of documentation and the associated regulatory reference.

COMMON CHART FORM	THINNING GUIDELINE**

Identification and Admission Documentation
Admission Record/Facesheet	Current Facesheet
Pre-admission Screening (PASARR)	Permanent
Preadmission Assessment/Intake	3 months after admission
Admission Consent Permanent	Financial/Administrative file
Admission Agreement	Permanent
History and Physical and Hospital Records
H&P Most	Current
Hospital Discharge Summary	Most Current
Hospital Transfer Form	Last Hospital Stay
Other Hospital Records(All hospital records received should be retained)	Retain pertinent records for 3 months after hospitalization then thin.
Immunization Records	Permanent
Advance Directives/Legal Documents
CPR Directive	Most Current
Resident Self Determination Act Acknowledgement.	Most Current
Living will	Most Current
Advance Directive	Most Current
Durable Power of Attorney	Most Current
Guardianship/Conservator	Most Current
Legal incapacitation	Most Current
Consents, Acknowledgements (For example, Physical Restraints Consent, Admission Consents, Consent to Treat, Consent to Photograph, MDS Consent, MDS Acknowledgement, Release of Information Consent, Release of Responsibility/Leave of Absence)	Most Current
Clinical Assessments (At a minimum, retain most recent assessment plus one previous)
Nursing Assessment	6 months to 1 year
Wound and Skin Assessments	6 months to 1 year
Fall Assessment	6 months to 1 year
Bowel and Bladder Assessment	6 months to 1 year
Pain Assessment	6 months to 1 year
Mini-Mental/Cognitive Exam	6 months to 1 year
Restraint Assessment	6 months to 1 year
Minimum Data Set and Care Plan
MDS	15 months readily available
Care plan	Current care plan
Specialty Care Plans ie: hospice/dialysis	Current plan
Care Plan Signature Records (if used)	Current plan
Care plan recap (if used)	Current plan
Physicians Orders
Computerized Recaps or Renewals	3 months
Telephone Orders	3 months
Interim orders	3 months
Protocols or Standing Order Policies (if used)	Current
Fax Orders	3 months
Physician and Professional Progress Notes/Consults
Physician Progress Notes	1 year
Cumulative Problem/Diagnosis List	Most recent
Annual Exams	Most recent
Other specialists/consultation	1 year
Dental Progress Notes/Exams	1 year
Podiatry Progress Notes/Exams	1 year
Psychological Evaluation	Current
Nursing Notes/InterDisciplinary Notes
Nursing Notes	3 months
Interdisciplinary Notes	6 months
Nursing Summary Forms/Flowsheets	3 months
Medication, Treatment and Other Flowsheets
Monthly Medication and Treatment Records	3 months
Vitals Sign Record	1 year
Weights Record	1 year
Intake and Output Records	3 months
Behavior Monitoring Records	3 months
Other Flow Sheets (Diabetic site rotation, etc)	3 months
Pharmacist/Drug Reviews Recommendations	1 year
Lab, X Rays, and Special Reports
Lab Reports (frequently ordered)	3 months
Annual or interim Lab Reports	1 year
X-Ray Reports	1 year
Special Diagnostic Tests	1 year
Rehabilitative Therapy (PT, OT, SLP)
Therapy Evaluation	Most Recent
Therapy Certificatio/Recertification	3 months
Progress Notes	3 months
Discharge Summary	Most Recent
Therapy Screen	Most Recent
*Once therapy is discharged thin therapy information for that discipline except the evaluation and discharge summary.
Rehab Nursing
Screen	Most Recent
Rehab Nursing Assessment	Most Recent
Progress Notes/Treatment Records	3 months
Social Service, Dietary (Nutrition Services), and Activities (Therapeutic Recreation)
History	Permanent
Progress notes	6 months to 1 year
Assessments	Most Recent
Misc
Clothing list or Inventory List (If required)	Most Current

*Common Chart Forms – The chart forms and location are not meant to represent a recommended chart order or forms. Chart order and the types of forms used are facility-specific. The forms named represent common types of documentation found in a long term care record.

** Thinning Guidelines – These guidelines are recommendations and provide a baseline. Each facility should adapt and develop thinning guidelines that meet the needs of their resident population and staff needs.

Integrating Hospital Documents into the Long Term Care Record
Hospital or another healthcare providers (i.e. another LTC facility) records that are sent with a resident to provide information for continued care and treatment should be retained by the facility. It is recommended that pertinent information such as the history and physical, discharge summary, and transfer form be kept in the medical record. All other records sent (copies of progress notes, labs, consults, etc.) should be kept for 3 months in the record to provide information when establishing the current plan of care and treatment and then thinned and retained in the resident’s overflow record. The records provided on admission, readmission, or return from the hospital should never be destroyed. See section x of this report for guidance on how to handle release of information or redisclosure of hospital and other healthcare provider documents.

A copy of the history and physical from the hospital is commonly accepted as the history and physical on admission to a LTC facility. When necessary, physicians are expected to update the H&P or to write a progress note that documents the resident’s current condition on admission.

Thinning the Medical Record

Each facility should develop a schedule for thinning the medical records. It is generally recommended that records are thinned quarterly and as needed schedule. Using the MDS/care conference schedule and thinning after the care conference can provide calendar for checking the chart to determine if thinning is needed.

Once the record has been thinned a notation should be made in the record. For example, a label can be placed in the inside cover of the chart that states the date the record was thinned. The records thinned from the chart should be filed in the overflow record immediately to assure that resident records are always accessible and easily retreivable.

Maintaining the Overflow Record of Thinned Documents

The overflow record is considered part of the resident’s active medical record. The overflow records which contain the documentation thinned from the chart must be systematically organized (a chart order should be established) and readily accessible. Because it is not always possible to keep all documentation in the chart holder at the nursing station, the thinned information is generally kept in the HIM department.

Standards for maintaining the overflow medical record:

SYSTEMATICALLY ORGANIZED:

For ease in locating documents a chart order should be developed for overflow records. It is recommended that the overflow chart order be the same as the discharge chart order to facilitate quick assembly upon discharge. All like forms should be filed together (i.e. all nurses notes together in date order). Use index tabs if desired to indicate the sections of the chart (index tabs from an office supply company work well in thin charts). Tabs will make retrieval and filing of documents easier.
Records should be maintained in date order. Facility policies should define if forms will be filed in chronological or reverse chronological order. Filing in chronological order is considered the gold standard, but reverse chronological would be acceptable defined in facility policy and consistently applied to all overflow records.

READILY ACCESSIBLE:

Overflow records should be filed in a location that is secure and readily accessible.
When overflow records are removed a chart locator or tracking system must be used to identify the individual removing the chart, the date, and the location.

Maintaining a "Soft Chart" or "Shadow Record" and Other Types of Records:

Soft charts are resident-specific records that are maintained by a discipline that contains extra notes, observations and copies of documentation kept in the medical record. The record is not usually integrated with the resident’s legal medical record. The soft chart is often a working duplicate of the medical record.

Soft charts are generally not recommended. The facility has legal risks because this type of record is discoverable in a legal process and could contain contradictory or damaging information. There is potentially a loss of critical information that should be documented in the medical record, but it is not.

If facility administration approves the use of soft charts, policies should be developed to manage the records with the same structure and organization as the resident’s legal medical record. The following systems should be developed for each type of soft chart:

Implement systems to assure that the records are physically secure such as retaining information in locked file cabinets with access by limited staff.
Policies should be developed to handle the confidentiality of information and documents contained in the record.
Records should be identified on the retention and destruction schedules.

Social Service and Financial Files:

Both social service and financial files are commonly maintained by long term care facilities. Both of these type of records are acceptable. They contain information that is highly sensitive and often not related to resident care. Policies must be developed to define what information is retained in each type of record. There is a risk with a social service file that information which should be documented in the medical record is kept only in the social service record. Along with guidelines to define what is contained in the file, policies should define security, confidentiality, retention and destruction.

Communication Records/Shift Worksheets:

Communication and Shift Records are a common form of communication between nursing staff working on different shifts. They usually contain multiple residents on one page and are not considered a formal part of the medical record. These records are acceptable but standards should be in place to assure that the medical record also reflects the resident’s condition, nursing observations, and assessment that are often found in the communication records. It is critical that the medical record contain the same information as the worksheets on condition, observation and assessments.

Facility policy should establish retention and destruction procedures. Determine where the reports will be stored, how they will be collected, how long they will be retained, and when they will be destroyed. In absence of a state law, it is recommended that shift reports be retained for 30 days and then destroyed.

Outpatient Records and Records Maintained by Vendors:

When vendors such as a therapy provider is contracted with a facility, it is acceptable for a the company to maintain their own medical record. The facility must ensure that the vendor providing outpatient services through the facility has appropriate policies in place to deal with security, confidentiality, retention and destruction.

If facility staff is providing outpatient services, the facility must develop and manage the record systems and procedures to assure security, confidentiality, retention and destruction. If the facility employs the therapists, it is not recommended that they have a separate therapy chart (soft chart). All documentation should be maintained in the medical record.

Forms Control Processes

HIM Standard: A procedure has been established to address issues related to the completion of all health record forms and data entry screens.

A process should be in place to review and approve new or revised forms. There should be a formal process such as a forms committee to carry out the following functions:

Forms should be titled and indexed. A master of each form should be maintained.
Review and approve new forms. New forms should be reviewed for content, potential duplication of information already being documented, and inclusion of basic identification information: Title of form, resident name, medical record number, page numbers ( page x of y) if applicable, form control number if applicable, and revision date.
Review and approve revisions to forms.
Identify forms which should be deleted or inactivated and assure that the form is no longer available for use.

AUDITS AND QUALITY MONITORING

The content, completion, timeliness and accuracy of medical record documentation is extremely important in a long term care facility. Documentation has a far-reaching effect on most aspects of the organization’s operation. The quality and type of care and services delivered to the resident are determined in part through documentation. On-going planning and assessment rely heavily on the quality and accuracy of the documentation in the chart. The medical record is also used to determine survey compliance, reimbursement, and serve as a source document for legal proceedings.

Proactive (concurrent) monitoring of the completion, timeliness and accuracy of the medical record documentation is critical. Both the need for good documentation and risk factors hindering quality support the importance of on-going, scheduled audits and monitoring for every resident’s medical record.

Qualitative vs. Quantitative Audits and Monitoring

There are two broad types of audits – qualitative and quantitative. Qualitative audits look at the quality of documentation assessing adherence to clinical practice guidelines, evaluating consistency in charting, and adherence to regulations, standards and interpretations. This type of audit is usually completed by a staff member or consultant who has professional training, education or experience. Qualitative audits are more subjective than quantitative. The auditor tries to determine if the proper care was delivered based on the documentation.

Facility staff can be trained to complete quantitative audits which focus on whether a document is complete (all sections of a form), authenticated, or timely rather than what the documentation states. A training process is necessary to help staff understand what they are to look for and why. This type of audit is more objective than a qualitative audit. Staff can usually determine if an audit element is in place or not (similar to a yes – no question).

On an on-going basis, facilities should have quantitative monitoring in place to assure complete and timely records. Admission, concurrent and discharge record monitoring assures that analysis is completed throughout the residents stay. The goal to continuous monitoring throughout a residents stay is to identify problems or omissions when correction is possible. Analyzing the record on discharge makes it virtually impossible to legally and ethically address or correct most documentation problems or ommissions. For example, if an assessment is not completed on admission nothing can be done on discharge, but if it is found during an admission audit the assessment can still be completed in order for the facility to provide appropriate care and services for the resident.
Assessing the Quality of Documentation

When completing a qualitative audit, the reviewer should have the ability to assess the following issues, identify strengths and weaknesses, and provide suggestions to correct future documentation discrepancies.
- Consistency in documentation between progress notes, assessments, care plans, etc.
- Duplication or redundancy in documentation.
- Contradiction in documentation without a clear reason for the differences. This may occur between two disciplines or within one discipline such as nursing where multiple staff members chart on a similar issue.
- Documentation that is missing key elements for the proper assessment or planning of a problem.
- Documentation reflects application of appropriate practice guidelines, standards, regulations, reimbursement rules, and clinical protocols across all disciplines.
- Understanding of the reason for all types of documentation in a long term care record and the underlying guidelines, standards, regulations, or clinical practice protocols.
A health information consultant should have the ability to provide a qualitative analysis of the documentation and content of the medical record and provide feedback and suggestions for problems identified.
Routine Audits/Monitoring (Criteria and Timeframes)

Every long term care facility should have systems in place for monitoring completion of their documentation on an on-going basis. At a minimum, records should be reviewed on admission and hospital return, concurrently on a quarterly basis, and upon discharge/death.Not all audit findings will be correctable. For findings that cannot be corrected, the information should be gathered for training/retraining, system evaluation and improvement.

The criteria in the following table can be used to develop and tailor audit and monitoring tools.

	Quantitative Monitoring Criteria
Admit/Return first 24 to 48 hours	Transfer form or order to admit received. Admission orders transcribed accurately from transfer form.’ All orders required per facility policy are verified or clarified by the attending physician notified. If transfer form not signed by physician, orders are verified by telephone or fax order. A diagnosis or reason is identified for each medication, ancillary service, treatment with billable supplies that are ordered. (Diagnosis in text of order, on diagnosis list, or through supporting physician documentation). Admission orders are signed and noted by a nurse as appropriate in accordance with facility procedure. Orders are transcribed accurately to MAR and TAR. All medication orders include the name of the med, dose, frequency, route, and if appropriate the duration. PRN orders should include reasons for administration. An initial care plan is implemented including diet and nursing care. Admission note is completed including time of admission, how resident was admitted, and condition of resident. Initial Medicare Certification is completed if applicable. Allergies are identified. Discharge plan is initiated if applicable (i.e. as required by Joint Commission Accreditation
	Face sheet or demographic information on record. H&P and Discharge summary requested from hospital if applicable and if not sent with resident. If H&P not completed prior to admission, an exam is scheduled per state requirements. Advanced directive acknowledgement is completed. A copy of the directive is in the record if applicable, physician orders coincide with resident directives. Inventory of personal effects is completed if applicable. Nursing Assessments and others required per facility policy are completed immediately upon admission are complete, timely and authenticated (e.g. skin assessment, fall assessment, etc.). (No missed sections or questions on the assessment without explanation). Admission vital signs, height, and weight are documented. Admission paperwork such as admission consents including the consent for use of protected health information, bill of rights acknowledgement, advanced directive acknowledgement, etc. Are completed per facility policy. PASARR documentation on record or review scheduled. Admission PPD read or TB test ordered. If not, documentation indicates if contraindicated or previously completed within an acceptable timeframe. Although it is not recommended to accept an order for restraints on admission, if physical restraints are ordered upon admission the order should include the type of physical restraint/device, the reason for use, the frequency of use and the restrictions for use. An initial assessment should have been completed for the use of the restraint. Informed consent has been obtained from the resident or their representative. Diagnosis list has been started and ICD-9-CM codes assigned. Labs, x-rays, consultation visits, etc. that were ordered upon admission have been scheduled. Assessments and monitoring records were initiated or completed per facility policy: Common forms include skin risk, fall risk, bowel & bladder monitoring, intake and output records, self-administration of meds, pain assessments, interdisciplinary assessments (dietary, activities, social service, chaplain), teaching/resident education plans, oral/dental assessment, restorative nursing assessments. If therapy has been ordered, the therapy plan of treatment/evaluation has been initiated no later than 48 hours. Physician orders have been clarified to include the specific therapy plan.
Admit/Return 14-21 days	The assessments listed in the 24-48 hour audit that were not initiated in that time frame should be audited during the 14-21 day audit. Items that were not complete on the admit and 24-48 hour audits are checked. 14 day Medicare Recertification has been completed if applicable. The 2^nd step of the PPD/TB test was administered and read (if applicable). The MDSs (both OBRA/regulatory and PPS if applicable). See the MDS audit criteria for specifics. Care plan is complete by day 21 (should be available for use by day 21)
RAI Process	The RAI process should be audited by someone independent of the process to assure compliance with completion and timeliness timeframes. Recommend auditing each MDS (OBRA/Regulatory and PPS). Basic tracking form complete and signed. All questions on the MDS are appropriately answered. On admission, MDS Face Sheet completed, signed and dated. A-3 Assessment Reference date within the proper range. R2b date and dates of staff completing the MDS are not prior to the A-3 date. Staff dates cannot be after the R2b date. Staff signatures include their title, sections completed and date completed. Triggered RAPs are identified in section V. For RAPs triggered, assessment documentation is shown in the location of information column. Date in VB2 is no later than day 14 after the start of the assessment period. (Admission no later than day 14, quarterly no more than 92 days between R2b dates, and annual no more than 366 days from last annual VB2 date). Date in VB3 is no more than 7 days after VB2. RAP documentation/assessments are completed prior to Vb2. If a RAP is identified to be care planned, the issue is addressed on the residents plan of care. Readmission/Return and Discharge Tracking forms are completed within 7 days of the event. Significant change assessment completed within 14 days after significant change in status is noted. Corrected MDS documents are called to the attention of the business office to assure that adjustment bills are completed if necessary.
MDS Validation Reports	The validation report is reviewed after each submission and appropriate follow-up is conducted to address errors.
Concurrent or Quarterly	Admission Record/Face Sheet: Check if any changes have been made on the face sheet page or any areas are inaccurate. Reprint a new face sheet if there are changes or inaccuracies. Diagnosis list updated and coded: Check if new diagnoses have been written on the diagnosis list. Check physicians orders, progress notes, referrals, etc. to see if the physician has documented any new diagnoses. Code new diagnoses, input into the computer, and print a new list. RAI Process: See RAI Audit Criteria Care Plan Current and Complete: Care conference held within 7 days of the MDS (either quarterly or full). All those in attendance signed the attendance record. Care plan is rewritten or reprinted if there are too many changes and it is difficult to read/use. Nursing Assessment and Monitoring: Assessments completed per policy. All entries are signed and dated. Monitoring records are completed and authenticated – no open holes or breaks in documentation. Restorative Program (if applicable): actual treatment time is documented for rehab nursing service delivery record, an assessment has been completed. Progress notes reflect residents status and progress. The care plan reflects restorative program and goals. Nursing Documentation: Nurses notes are signed and dated. Follow-up charting complete for incidents/falls. Medicare charting completed when applicable Weekly/monthly summary or case mix charting completed as applicable. Physician Orders – Renewals: Physician has signed and dated the renewals in the specified timeframe. Orders did not expire before being resigned. Nursing noted orders upon return per facility policy. Telephone and Fax Orders: All telephone orders (TO's) are complete, signed and dated. All original telephone orders have been returned within the appropriate time frame. All orders given by a physician has a corresponding signed order (TO, fax order, signed physician referral, etc.). Physical Restraints: If ordered, current assessment completed, informed consent documented, order matches device in use. Documentation includes alternatives tried before restraint used and the symptom being treated.. Psychotropic, Antipsychotic, Hypnotic medication Monitoring: If ordered, monitoring assessments completed, signed and authenticated. Side effect monitoring completed. Dose reduction documentation or justification on record. Physician Visits: Visits are made timely. Progress notes written or dictated notes sent back and filed. Notes are authenticated and dated. Required NP/PA and physician visits alternate. Physician referrals are complete and noted by the nurse receiving. Orders on physician referral have been verified with the attending if appropriate and transcribed accurately. Documentation of consults for dental, vision, podiatry, audiology/hearing aid, hospice, and psychological services are in record when applicable. Vital Sign Records: Vitals completed and recorded in a timeframe consistent with facility policy and state regulation where applicable. Weights recorded monthly or per facility policy/state regulation where applicable. Changes in weight (5% in 30 days/10% in 6 mo.) noted in record for possible significant change assessment. Medication and Treatment Record (MAR/TAR): Look for open holes on the MAR/TARs. PRN records signed, reason and result documented. Other flowsheets are complete. All flowsheets and MAR/TARs have resident name, MR#, month and year identified on every page. Pharmacist review conducted monthly. Medication disposal/destruction records are complete. Documentation signed and dated. Labs: All orders for labs (routine and stat) have a corresponding lab report in chart. Labs are noted and dated by nursing. Lab results are communicated to physician. Social Service Documentation: Each quarter a progress note or assessment form is completed at the time of care conference noting changes to be made to the care plan. Updates are completed on the Social History. Entries on all documentation are signed and dated. Dietary/Nutrition Documentation: Each quarter a progress note or assessment form is completed at the time of care conference noting changes to be made to the care plan. Intake monitoring records are completed as appropriate. All entries are signed and dated. Activity Documentation: Each quarter a progress note or assessment form is completed at the time of care conference noting changes to be made to the care plan. All entries are signed and dated. Rehabilitation Documentation (PT, OT, SLP): Documentation for each therapy is filed together (all PT doc. together, etc.) For residents currently treated, service delivery record are completed, treatment time documented, signed and dated, progress notes are written at least every seven days, the physician plan of care/evaluation/cert/recert has been completed and signed by the therapist and physician. A current physician order is on record matching the current treatment plan. Chart Thinned: The chart is thinned per thinning schedule. Forms are repaired. Chart is cleaned and organized.
Discharge Analysis	Chart is placed in discharge chart order per facility policy. All Forms have Name/MR#. Discharge Plan of Care or Discharge Instructions or Transfer Form: All sections are completed, signed and dated by appropriate discipline(s) Resident received a copy of discharge plan/instructions which has been written in layman’s terms. Recap of stay documented for planned discharged. Physician Discharge Summary completed if required by State law. Initiated by facility staff. Physician completed, signed and returned within 30 days of discharge unless other time frame required by State law. Discharge Order: Discharge order obtained for the day of discharge Order included discharge destination, if meds sent when transferring to another facility include statement in order. Order upon death states to release the body or documentation of physician notification on record. Discharge order has been signed, dated and returned by the physician Orders: Renewals / Telephone Orders (TO's): All renewals have been returned and signed All TO's have been returned and signed. Facility policy should define how to handle orders that have not been returned. Discharge documentation: There is documentation of events leading to discharge or death: Nurse wrote a note reflecting date and time of discharge, the resident's disposition, condition of the resident at discharge, where discharged to, and the individual taking responsibility for the resident. Disposition of medications documented per facility policy. Disposition of personal belongings: Inventory of Personal Belongings completed on discharge; or documentation of belongings sent with resident or picked up by the family documented in notes. DC Diagnoses coded and indexed per facility policy. MDS Discharge Tracking form completed within 7 days of discharge. DEATH ONLY: Nurses notes reflect physician notification Nurses notes reflect family notification Mortician Receipt completed.

4.2.4 Focus Audits and Monitoring Systems

There are other beneficial audit and monitoring systems, many of which should be in place on an on-going basis. Focus audits should be implemented based on the needs and issues of a facility. The following table lists the common monitoring and focus audits found in long term care facilities.

	Quantitative Monitoring Criteria	Qualitative Monitoring Criteria
Acute Problems/24 Hour Board(completed daily)	Review the 24 hour or acute problem board each day. For each resident and problem identified check to see if corresponding documentation was completed such as nurses note, monitoring record, etc.	Not only verify that the documentation was done, but also analyze what was documented. Does a note contain information applicable to the problem, should other issues be addressed? If an assessment or plan was documented was it appropriate? Should the documentation have included an assessment or plan?
Weights	Implement an on-going monitoring system when weights are recorded to note significant weight loss changes.	If a significant weight loss has occurred review the documentation content to determine if the assessment and plan are complete and appropriate.
Physician Visits	Monitoring system to assure that physician visits are made and documented every 30 days for the first three visits and then every 60 days thereafter. Assure dictation is returned if applicable.	Content of the progress note addresses or supports resident issues.
Physician Orders/ Renewals	Reviewed and signed by the physician within specified time frame. Renewal of orders completed timely (i.e. 30 or 60 days).	Diagnosis can be associated with orders; Check for duplication of medications or treatments in treating a diagnosis.
MAR/TAR	Documentation completed at time of administration or within 24 hours if documentation omission occurs.	Reason and results are documented for PRN administration.
Physical Restraints	Assessment completed and reviewed/updated at least quarterly. Consent obtained from resident or responsible party. Physician order obtained.	Reason for restraint is appropriate to justify use.
Skin/Pressure Sore	Assessment completed and reviewed/updated weekly until healed.	Documentation shows improvement or modification of plan if no improvement.
Psychotropic, Antipsychotic, and Hypnotic Medication Use	Assessment completed and reviewed/updated at least every 6 months. Physician order obtained.	Diagnosis associated with medication is listed in the federal regulations as appropriate. Continued justification for administration of medication is documented. Dose reduction efforts are documented.
Lab Result Monitoring	Results of physician orders for all labs are in the medical record.	Documentation reflects that abnormal lab results are communicated with physician.

Integrating Audits/Monitoring into the QA/QI Program

In order for an audit and monitoring program to be effective the data collected should be managed, analyzed, and reported. Findings from both focus audits/monitoring and on-going systems should be reported at the quality assurance committee meeting. Trends or problem areas should be identified and action taken to correct the negative finding. Using a quality improvement process, the problems identified through the audit should be analyzed, measures taken to correct the problem, and further monitoring to determine compliance.

It is recommended that audit findings are plotted or graphed over time to show potential negative trends, the result of improvement efforts, or results of on-going monitoring. Not every audit or monitoring criteria warrants reporting and graphing. Facility administration, health information practitioners and the QA committee should determine which audit criteria are appropriate for on-going reporting and graphing.

It is critical that the health information coordinator/manager actively participates in the quality assurance committee and process. If this is not possible due to level of staffing and level of expertise, it is acceptable to have other clinical staff assist in the collection of audit data and in the analysis and reporting process to the QA committee. Once on-going audit and monitoring processes are established, there is a system in place that can be adapted to the changing needs of the facility. For example, if a potential problem area is identified on the quality indicator report, the audit tools can be adapted to monitor related documentation issues as one method to analyze a possible problem. The elements of an effective audit and quality monitoring system include flexibility to adapt to the changing needs of the facility, formal reporting and correction methods, and administrative acknowledgement of the importance of proactive monitoring systems.

Retention of Audits, Checklists, and Monitoring Records

If checklists are placed on the chart, it is acceptable to leave them on the record, but only for the time frame defined on the tool and then it should be removed (eg. An admission checklist that is completed by day 7 should be removed right after the 7^th day). It is not recommended the audit forms be left in the chart even discharge audit tools.

The retention policies for the facility should define how long audits, checklists, and monitoring records should be retained based on the need and further use for the information. Generally, once the tool is completed and the findings are used for statistical analysis where applicable, the checklists/audit forms can be destroyed. If an audit is used in conjunction with a survey correction plan or monitoring a quality indicator, adjust the retention schedule appropriately.

DISCHARGE RECORD PROCESSING

Processing of discharge records is an important aspect in management of record systems. For all records including discharge records it is the responsibility of the long term care facility to protect the records from loss, destruction and unauthorized use. Prior to final filing of a discharge record, audit and monitoring systems should assure that the record is complete. This section reviews the fundamental processes that should be in place when managing discharge records.

Discharge Record Assembly

Discharge assembly is the process of pulling together all medical records for a resident upon discharge
and assembling the medical record into one combined chart (which can have
multiple volumes) in the established discharge chart order. The established
order provides for a discharge record that is systematically organized.
It is recommended that a discharge chart order or order of filing be placed
in each record to facilitate location and retrieval of information.

Pulling Records from Multiple Locations:

When assembling the discharge record pull records from all locations. For example, all overflow records for the resident, therapy records not yet filed in the chart, records kept in a separate notebook/cardex such as the MDS or care plan, records that are not kept in the chart such as an individual resident’s sign-out log kept in a sign-out book, and other records that have not yet been filed in the chart.

Discharge Chart Order:

Place the records in discharge chart order. Facility policy should define a specific discharge chart order that is used consistently for all discharge records. It is recommended that the discharge chart order remain the same as the in-house chart order to eliminate unnecessary time moving sections of the chart around. The only change that is recommended for the discharge chart order is to place the discharge documentation (discharge plan of care, transfer form, etc) at the front of the chart behind the face sheet/admission record. If there are records not normally kept in the chart during the resident stay, but filed on discharge, they should be added to the discharge chart order.

The key to the assembly process is to establish one consistent chart order and date order for the forms and follow it consistently through all discharge records to establish systematically organized records that facilitate ease in retrieval of information. The following are the accepted methods for organizing discharge records.

Charts placed in discharge chart order running in chronological order.
Charts placed in discharge chart order running in reverse-chronological order.
Another approach when used systematically may reduce staff time yet allow for an organized record by placing the active chart in discharge chart order and maintain as volume one of the discharge record (either chronological or reverse chronological date order). The overflow records become the subsequent volumes of the discharge chart. A chart order or order of filing is placed at the front of volume one. The overflow records are placed in a defined chart and date order to use this method for assembling discharge records.

Date Order for Discharge Records:

There are two acceptable methods for the order of filing chart forms -- chronological date order (oldest records filed first) or reverse chronological date order (most recent records filed first). It is considered technically correct to file the discharge medical records in chronological order by form on the chart order (for example, all nurses notes kept together in chronological order, all physician orders recaps in chronological order, etc.)

If defined by facility policy and consistently applied through the discharge record, forms could be filed in reverse-chronological order. If using a reverse-chronological order, all records in the discharge chart and on the discharge chart order should follow this organization.

Fastening Discharge Records:

To prevent loss or destruction of individual records, it is recommended that all discharge records be fastened in some manner. The most common methods include:

Two-pronged metal fasteners. If using a standard file folder, the prong should fasten the records to the file folder.
Specialty fastener rubber bands that are used for record storage. They have a life-span equal to the retention period for the medical records and fasten the records around both the length and width of the pages.
Pocket accordion folders in combination with a metal fastener or rubber band fastener. If using a metal fastener, it should not be fastened to the file folder since records must be lifted out of the pocket folder for review.

Discharge Record Folders and Labeling:

Discharge records should be placed in file folders that are labeled with resident identification information. The type of file folder used should be dictated by the storage method used for filing. For example, if using shelf filing the file folder should have a side tab to place resident identification information. If using drawer style file cabinets, the file folder used should have a top tab for resident identification information.

At a minimum the discharge record file folder should be labeled with the following information: Resident full name, admission date, discharge date, medical record number and volume number. Other information which could be include on the label is the physician name and the discharge disposition (discharged home, another nursing home, expired, etc.). The number of volumes should be included on all discharge records even if there is only one record and should note both the volume number of that folder and the total volumes for that record (volume 1 of 2, etc.). It is recommended that a label with the discharge year be placed on the file folder to be used as a reference in the retention and destruction process.

Other information and labels can be placed on the file folder to aid in filing and locating a record. Depending on how sophisticated of a filing system is used, color coded labels with information such as the first three letters of the last name or numbers in the medical record number provide additional assurances that records are filed correctly and can be located easily.

In maintaining a unit record, the medical records from a previous stay should be pulled forward and kept with the current admission. Once the resident has been discharged from their most recent admission, the records from previous stays should be filed with the last admission. Do not integrate the records from a previous stay with the last admission. Keep the previous records in their file folders. Relabel the folder with the year from the most recent discharge. File the records from the previous stay in chronological order behind the last volume of the most recent stay.

Discharge Record Analysis

The process of analyzing a discharge record entails completing an audit of required discharge documentation before it is filed with the other discharge records. When completing discharge analysis the following steps should be completed:
- Initiate a discharge audit form to record audit findings and deficiencies.
- Check all pages of the medical record for resident name and medical record number. This will assure that a document if separated from the record can be traced back to the correct resident. Make sure that all documents belong to the correct resident.
- Complete a discharge audit focusing on those elements outlined in discharge analysis in section 4.2.3 – Audits and Quality Monitoring.
- Note on the discharge audit those items that are missing or incomplete. Note items that have been mailed or are waiting return.
If the discharge audit is kept on the incomplete record, it should be removed before filing it with the other completed discharge records or when the record is requested by an outside party.
Timely Completion of a Discharge Record

HIM STANDARD: Written policies on record completion are in place and are consistent with accreditation standards, regulatory requirements, and medical staff guidelines.

Records should be assembled, analyzed, and completed within 30 days of discharge unless state law specifies another time frame. A record should be removed from the station as soon as possible after discharge. Records should be removed within 24 – 48 hours, but no more than 72 hours after discharge. The initial assembly and analysis should take place within 5 days of discharge. This leaves the remaining time to follow up on deficiencies and track documents that are being mailed and still allow for timely completion of the discharge record.
Incomplete and Delinquent Records

HIM STANDARD: Written policies outline the organization’s standards for the timely and accurate reporting of delinquent records.

Upon discharge analysis, records that have specific deficiencies that can be completed by a health care provider are considered incomplete. Once the audit has been completed, the providers should be notified of the incomplete records. They should be informed of the expectation to complete these records within a specific timeframe (within the 30 day or state-specific timeframe for timely completion of discharge records). Records should be monitored within the 30 day period to assure deficiencies are completed. If records have been mailed and were not returned in a timely manner follow up requests should be made for their return in time to meet the 30 day deadline.

Once an incomplete medical record remains so after a defined period of time (over 30 days or over the state-defined timeframe), the medical record is considered delinquent. A long term care facility can develop a quality assurance monitor by calculating the delinquent record rate or reporting the number of delinquent records each month. To calculate the delinquent record rate divide the total number of delinquent records by the average number of discharges in a defined period. For example, if there are 30 total delinquent records and the average number of discharges for a 30-day period is 45 then the delinquent record rate is 67%.

An on-going quality improvement process should be used to monitor the types of deficiencies in discharge records and the reasons for records to become delinquent, identify the causes for the deficiencies and delinquencies, and then implement corrective measures. The number of delinquent records, delinquent record rate and reasons for delinquency can be reported at the Quality Assurance Committee meetings. Completing a run chart with the number of delinquent records and delinquent record rate each month can show a pattern over time. When records cannot be completed, a process should be established to review and approve of records to be filed with the other discharge records as incomplete.

Maintaining A Control Log for Discharge Records

It is important to maintain a monitoring system or control log for managing the completion of discharge records. The following table can be used to track records through the process:

Discharge Date	Resident Name	Assembled	Analyzed	Coded	Completed	Miscellaneous

When to Close a Record on Temporary Absence
Facility policy should define when a record will be closed upon a temporary absence and when it will remain open. Federal law does not dictate when records must be closed and when they remain open on a temporary absence. Most state laws do not address this issue, however, if there is a specific state statute follow the regulation. A temporary absence would be such events as a temporary leave of absence with or without a paid bed hold or a transfer/discharge to the hospital with the expectation of return with or without a paid bed hold.

Long term care facilities should determine how they will handle closing records upon a temporary absence and consistently apply the policy in their facility. A good rule of thumb to help decide when to keep a record open upon a temporary absence is how the MDS discharge tracking form is completed. If it is indicated on the MDS discharge tracking form that the resident is not anticipated to return the chart should be closed and the resident discharged. If it is anticipated that the resident will return, facility policies should define whether the record will remain open or be closed. Facility policies should specify how each of the following situations will be handled and consistently applied. Policies may be different for each type of temporary discharge and/or by payer type.
- Hospitalization with paid bed hold
- Hospitalization without paid bed hold
- Leave of absence with paid bed hold
- Leave of absence without paid bed hold
- Other types of temporary absences as defined by facility policy
There are advantages and disadvantages to each option outlined below.
- Keeping a Record Open Upon Discharge for a Temporary Absence: One option is to keep the record open during a temporary absence rather than closing the record on the discharge/transfer date. The advantage to keeping the record open is to minimize the time in readmitting and reassessing the resident. The information prior to the temporary absence continues to be available rather than in another record that is less accessible. The disadvantage of leaving the record open is the lack of consistency between the admission and discharge date, the financial record, and the medical record.
  
  If the record remains open, policies should define the maximum length of time a record will remain open. Some payers such as Medicaid may define a bed hold period which can be followed in developing a time frame on keeping a record open. In absence of a state or payer specific guideline, keep a record open for no more than 14 days. If the resident has not returned within a 14 day period, the chart should be closed. The discharge date is the date the resident left the facility.
  
  When the chart remains open, the medical record should be removed from the nursing station or flagged for an absence or leave. This will help prevent staff from charting when the resident is no longer in the facility. A common practice is to redline the chart with a hospitalization. The pages in the record used for cumulative or on-going documentation such as progress notes, orders, flowsheets, or medication and treatment records are lined with a red pen with the hospital dates noted. This provides a visual break or flag in the record.
  
  Upon return from a temporary absence, facility policy should also define the documentation to be completed when the resident returns. The reason for the discharge will affect the type of documentation to be completed. A return from a 5 day leave of absence will probably not require the same type of reassessment as a return from a 5 day hospital stay. When the resident is readmitted, all of the current assessments and care plan should be reviewed and updated, a readmission physical assessment completed, an assessment for significant change in condition, readmission/assessment notes written by all disciplines, and new physician orders initiated.
- Closing the Record with a Temporary Absence: Another option is to close the record upon the discharge date for the temporary absence. Closing the record keeps the admission and discharge dates consistent with the financial record and medical record. If the record is closed, records from the last stay must be brought forward to the new record to assure access to important clinical information and provide continuity of care.
When pulling documentation forward to the new record a copy of the following documentation should be made: last MDS (if resident was expected to return from the temporary absence, the MDS schedule should resume not start over), advanced directives, social history, immunization records, leisure interest survey, copy of last progress notes, preadmission screening documentation (PASARR).
1. Closing Records with a Change in Level of Care
  The medical record should not be closed when there is a level of care change between NF and SNF – the same record should remain active through the level of care change. If a long term care provider offers services in a variety of licensure settings, organization policies should define how transfers between different levels of care will be handled. Transfers between similar levels like NF and SNF should not result in the closure of records. Major changes in level of care such as a transfer between an assisted living facility to a SNF should result in the records being closed if the resident does not anticipate returning to their previous living situation. If a resident anticipates a return, organization policies can determine if records will remain open, the maximum length of time records will remain open, or if they will be closed.
2. Closing Records with a Payer Change
  The medical record should not be closed upon change in payer such as a change from Medicare to private funds. A change in payment status does not warrant separating the medical records into different stays. The financial office should have mechanisms to track dates of coverage by individual payers.

FILING AND RETRIEVAL
STORAGE SYSTEMS:

HIM STANDARD:
- Policies and procedures exist to facilitate the storage of both active and inactive health records and resident-identifiable data and are evaluated periodically to ensure that health records and data are well organized, are kept confidential and secure, and are readily available for resident care, research, education, and other authorized uses.
- The storage system is designed and implemented to ensure the safety, security, and accuracy of health records and resident identifiable data.
- When storage plans are developed, consideration is given to the amount of space needed and available, the expected future demand for storage space, the costs of various storage alternatives and associated personnel, and the healthcare organization’s health record and data retention policies.
  Long term care facilities must invest in adequate storage systems and storage space for their medical records. The storage methods and systems must be secure and protect the confidentiality of resident information. The storage system and space must be adequate to protect the physical integrity of the record and prevent loss, destruction, and unauthorized use.
1. Storage System Options:
  
  Medical record storage systems should be of professional quality to house and protect the medical records. Office supply and medical record file and storage vendors offer various products ranging from simple file cabinets to mobile file storage systems. The most common found in long term care are open shelf filing shelves (with or without locking doors) or metal drawer file cabinets. The storage method selected is dependent on the security of the health information office and the amount of storage. If the office is to be shared with another staff member or department not in health information, the shelves or file cabinets must be lockable and kept locked when ever health information staff are not in attendance.
  
  The goal in each facility should be to keep accessible as many years as possible of discharge records.
  - Open shelf filing: Open shelf filing is a common filing method for medical records in various practice settings in health care. Open shelf filing allows for easy access to files. The file folders used with open shelf filing must have side tabs for viewing demographic information for identification.
    
    If medical record files are retained in the health information office that is not shared with other staff or in a separate locked file room, open shelf filing without lockable doors is acceptable. The office should always be locked when staff is not in attendance. If the office is shared, the open shelf filing should have doors that are lockable. When the health information staff member is out of the office, all medical records should be in locked files.
  - File cabinets: Two, four or five drawer metal file cabinets are also commonly used in long term care facilities. File cabinets work well when there are few discharges in a year and storage space is minimal. Because file cabinets are bigger and bulkier than open shelf filing, they are not the optimal choice for large storage rooms or offices with a large volume of discharge medical records.
    
    Locked file cabinets should be used when the health information office is shared with another staff member. The cabinets should be locked whenever the health information staff is not in the office.
2. Security Issues: Locking of Office and Storage Areas
3. Alternative Storage Areas
RETENTION

HIM STANDARD:

The healthcare organization’s and health information management department’s health record and data retention systems, policies, procedures, and specified periods of retention comply with federal and state regulations; certification, licensure and accepted standards of practice.
The retention system is designed and implemented to ensure the safety, security, and accuracy of health records and resident-identifiable data, and it considers the needs of all legitimate users of health records and resident-identifiable data.
Health information management department provides assistance to other departments in developing retention schedules for their records, data, indexes, and reports.

Facility policy should define a specific retention schedule for different types of records based on federal and state law and professional practice standards. The policy should be consistently applied and records destroyed after the retention period has expired. Storage areas should be organized and storage boxes labeled with the content, year of documents, and year records/documents can be destroyed.

Retention Guidelines

The following retention schedule outlines federal guidelines and recommended retention guidelines. If State law requires a different retention period, the more stringent between federal and state must be followed. After considering the required retention period, every facility should define in policy their specific retention period not to be less than the period defined by state or federal law.

Document Type	Federal Regulation	AHIMA Recommended Guideline
Medical Record	(F515) 5yrs after discharge when there is no requirement by state law; For minors, 3 years after the resident reaches legal age as defined by state law. Medicare residents – 5 years after the month the cost report is filed (HIM 12 Medicare Manual).

4. PRACTICE GUIDELINES FOR LTC HEALTH INFORMATION AND RECORD SYSTEMS

RECORD SYSTEMS, ORGANIZATION AND MAINTENANCE:

Integrating Hospital Documents 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)

4.2.4 Focus Audits and Monitoring Systems

Integrating Audits/Monitoring into the QA/QI Program

Retention of Audits, Checklists, and Monitoring Records

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

FILING AND RETRIEVAL

Separate Location for Incomplete Records

Typical Filing Systems

After Hours Retrieval

STORAGE SYSTEMS:

Storage System Options:

Security Issues: Locking of Office and Storage Areas

Alternative Storage Areas

RETENTION

Retention Guidelines