Health Information P&P Checklist

The following list provides an example of the types of policy and procedures that may be included in a manual for health information services. The titles and content of the policy and procedures may vary by facility or corporation. Some of the policy and procedures are listed more than once for cross-referencing purposes.

Abbreviations

Access, to Automated/Computerized Records

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

Admission/Discharge Register

Admission Procedures

• Facility Procedures – Establishing/Closing the Record

• Preparing the Medical Record

• Preparing the Master Patient Index Card

• Re-Admission – Continued Use of Previous Record

• Re-Admission – New Record

Amendment of Clinical Records

Audit Schedule

Audit and Monitoring System

• Audit/Monitoring Schedule

• Admission/Readmission Audit

• Concurrent Audit

• Discharge Audit

• Specialized Audits (examples)

• Change in Condition

• MDS

• Nursing Assistant Flow Sheet

• Psychotropic Drug Documentation

• Pressure Sore

• Restrictive Device/Restraint

• Therapy

Certification, Medicare

Chart Removal and Chart Locator Log

Clinical Records, Definition of Records and Record Service

General Policies

• Access to Records

• Automation of Records (See also computerization)

• Availability

• Change in Ownership

• Completion of Records

• Confidentiality

• Indexes

• Ownership of Records

• Permanent and Capable of Being Photocopied

• Retention

• Storage of Records

• Subpoena

• Unit Record

Closing the Record

Coding and Indexing, Disease Index

Committee Minutes Guidelines

Computerization and Security of Automated Data/Records

Confidentiality – See Release of Information

Consulting Services for Clinical Records and Plan of Service

Content, Record (the list provided is not all inclusive and should be tailored to the facility/corporation)

• General

• Advanced Directives

• Transfer Form/Discharge Plan of Care

• Discharge Against Medical Advice

• Physician Consultant Reports

• Medicare Certification/Recertification

• Physician Orders/Telephone Orders

• Physician Services Guidelines and Progress Notes

• Physician History and Physical Exam

• Discharge Summary

• Interdisciplinary Progress Notes

Copying/Release of Records - General

Correcting Clinical Records

Data Collection/Monitoring

Definition of Clinical Records/Health Information Service

Delinquent Physician Visit

Denial Letters, Medicare

Destruction of Records, Log

Disaster Planning for Health Information

Discharge Procedures

• Assembly of Discharge Record

• Chart Order on Discharge

• Completing and Filing Master Patient Index Card

• Discharge Chart Audit

• Notification of Deficiencies

• Incomplete Record File

• Closure of Incomplete Clinical Record

Emergency Disaster Evacuation

Establishing/Closing Record

Falsification of Records, Willful

Fax/Facsimile, Faxing

Filing Order, Discharge (Chart Order)

Filing Order, Inhouse (Chart Order)

Filing System

Filing System, Unit Record

Forms Management

Forms, Release of Information

Forms, Subpoena

Guide to Location of Items in the Health Information Department

Guidelines, Committee Minutes

Incomplete Record File

Indexes

• Disease Index and Forms for Indexing

• Master Patient Index

• Release of Information Index/Log

Inservice Training Minutes/Record

Job Description:

• Health Information Coordinator

• Health Unit Coordinator

• Other Health Information Staff (if applicable)

Late Entries

Lost Record – Reconstruction

Master Patient Index

Medicare Documentation

• Certification and Recertification

• Medicare Denial Procedure and Letter

• Medicare Log

Numbering System

Ombudsman, Review/Access to Records

Omission, Willful

Order of Filing, Discharge

Order of Filing, Inhouse

Organizational Chart for Health Information Department

Orientation/Training of Health Information Department

Outguides

Physician Visit Schedule, Letters, and Monitoring

Physician Visits, Delinquent Visit Follow-up

Quality Assurance

• Health Information participation

• QA Studies and Reporting

Readmission – Continued Use of Previous Record

Readmission – New Record

Recertification, or Certification (Medicare)

Reconstruction of Lost Record

Refusal of Treatment

Release of Information

• Confidentiality

• Confidentiality Statement by Staff

• Copying/Release of Records – General

• Faxing Medical Information

• Procedure for Release – Sample Letters and Authorizations

• Redisclosure of Clinical Information

• Resident Access to Records

• Retrieval of Records (sign-out system)

• Subpoena

• Witnessing Legal Documents

Requesting Information

• From Hospitals and Other Health Care Providers

• Request for Information Form

Retention of Records and Destruction after Retention Period

• Example Statement for Destruction

• Retention Guidelines

Retrieval of Records

Security of Automated Data/Electronic Medical Records

• General Procedures

• Back-up Procedures

• Passwords

Sign-out Logs

Storage of Records

Telephone Orders

Thinning

• In house Records

• Maintaining Overflow Record

Unit Record System

References:

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