LTC Health Information Practice & Documentation Guidelines

INTRODUCTION
ROLE OF HEALTH INFORMATION STAFF IN LONG TERM CARE FACILITIES
1. Job Qualification, Responsibilities, and Functions of Health Information Staff in a LTC Facility - Updated 6/09
  1. Role of the Credentialed Consultant
  2. Role of the Credentialed Practitioner Working in a Long Term Care Facility
  3. Role of the Non-Credentialed Practitioner Working in a Long Term Care Facility
  4. Role of the Health Unit Coordinator
  5. Evolving Role of Health Information
2. Health Information Department Staffing
HEALTH INFORMATION CONSULTANT SERVICES
1. Frequency of Consultant Visits
2. Performance Expectations for a Consultant
3. Consultation Reports
  1. Timeliness of Consultation Reports
  2. Content of Consultation Reports
  3. Distribution of Consultation Reports
  4. Retention (Facility and Consultant)
4. Evaluating Consulting Services
PRACTICE GUIDELINES FOR LTC HEALTH INFORMATION AND RECORD SYSTEMS
1. Record Systems, Organization and Maintenance - Updated 6/09
  1. Maintaining a Unit Record
  2. Assigning a Medical Record Number
  3. Maintaining Records in a Continuum of Care
  4. Defining What is Part of the Medical Record
  5. Maintenance of the Chart
  6. Identification/Name and Medical Record Number on Pages
  7. Common Chart Forms and Thinning Guidelines
  1. Maintaining the Overflow Record of Thinned Documents
  2. Maintaining a "Soft Chart" or "Shadow Record" and Other Types of Records
  3. Forms Control Processes
2. Audits and Quality Monitoring - Updated 11/08
  1. Qualitative vs. Quantitative Audits and Monitoring
  2. Assessing the Quality of Documentation
  3. Routine Audits/Monitoring (Criteria and Timeframes)
  4. Focus Audits and Monitoring Systems
  5. Integrating Audits/Monitoring into the QA/QI Program
  6. Retention of Audits, Checklists, and Monitoring Record
  7. Auditing the Electronic Health Record
3. Discharge Record Processing - Updated 6/09
  1. Discharge Record Assembly
  2. Discharge Record Analysis
  3. Timely Completion of a Discharge Record
  4. Incomplete and Delinquent Records
  5. Maintaining a Control Log for Discharge Records
  6. When to Close a Record on Temporary Absence
    1. Closing Records with a Change in Level of Care
    2. Closing Records with a Payer Change
4. Filing and Retrieval - Updated 6/09
  1. Separate Location for Incomplete Records
  2. Typical Filing Systems
  3. After Hours Retrieval
5. Storage Systems - Updated 6/09
  1. Storage System Options
  2. Security Issues: Locking Office and Storage Areas
  3. Alternative Storage Areas
6. Retention - Updated 6/09
  1. Retention Guidelines
7. Destruction - Updated 6/09
  1. Acceptable Methods of Destruction
  2. Abstracting Documents Prior to Discharge
  3. Destruction Logs and Witnesses
8. Physical Security of Manual/Paper Records - Updated 6/09
  1. Maintaining a Record Checkout System
  2. What To Do If a Record Is Lost, Destroyed or Stolen
  3. Disaster Plans
9. Confidentiality and Release of Information - Updated 6/09
  1. Identification of Confidential vs. Non-Confidential Information
  2. Resident Access to Their Records
  3. Confidentiality, Training and Agreements with Employees and Volunteers
  4. Resident Identification Boards at Nursing Stations
  5. Maintaining an Access/Disclosure Grid for Employees, Contractors and Outside Parties
  6. Handling a Request for Medical Records
    1. Review of Authorization for Release of Information
    2. Preparing a Record for Release
    3. Turn Around Time for Responding to a Request for Copies of Medical Records
    4. Copy Fees for Release of Information
    5. Documenting the Release of Information (Accounting of Disclosures)
  7. Redisclosure of Health information
    1. Redisclosure Upon Transfer to Another Healthcare Facility
  8. Handling Telephone Requests for Information
  9. Transmitting Patient Information Via Facsimile
  10. Responding to a Subpoena or Court Order
  11. Removing Original Records from the Facility
  12. Notice of Information Practices
  13. Designation of a Privacy Officer
10. Coding and Reimbursement - Updated 6/09
  1. Training and Resources
  2. Frequency of ICD-9-CM Coding
  3. Coding and Billing Relationships
  4. Investigation of Claim Rejection/Denials Due to Coding
  5. Coding Issues Under Consolidated Billing
11. Indexes and Registries
  1. Master Patient Index
    1. Maintaining an MPI
    2. Minimum Content
  2. Admission/Discharge Register
  3. Disease Index
12. Minimum Statistical Reporting
  1. Total Admissions
  2. Total Discharges
  3. Average Daily Census
  4. Total Census Days
  5. Length of Stay
  6. Percentage of Occupancy
LEGAL DOCUMENTATION STANDARDS
1. Purpose and Definition of the Legal Medical Record
2. Legal Documentation Standards
  1. Defining Who May Document in the Medical Record
  2. Linking Each Entry to the Patient
  3. Date and Time on Entries
    1. Timeliness of Entries
    2. Pre-dating and Back-dating
  4. Authentication of Entries and Methods of Authentication
    1. Signature
    2. Countersignatures
    3. Initials
    4. Fax Signatures
    5. Electronic/Digital Signatures
    6. Rubber Stamp Signatures
    7. Authenticating Documents with Multiple Sections or Completed by Multiple Individuals
  5. Signature Legends
  6. Permanency of Entries
    1. Printers
    2. Fax Copies
    3. Photo Copies
    4. Carbon Copy Paper (NCR)
    5. Use of Labels in the Medical Record
  7. Specificity
  8. Objectivity
  9. Completeness
  10. Use of Abbreviations
  11. Legibility
  12. Continuous Entries
  13. Completing All Fields
  14. Continuity of Entries – Avoiding Contradictions
  15. Condition Changes
  16. Document Informed Consent
  17. Admission/Discharge Notes
  18. Notification or Communications
  19. Delegation
  20. Incidents
  21. Make and Sign Own Entries
  22. Appropriateness of Entries – Keep Documentation Relevant to Patient Care
3. Legal Guidelines for Handling Corrections, Errors, Omissions, and Other Documentation Problems
  1. Proper Error Correction Procedure
  2. Handling Omissions in Documentation
    1. Making a Late Entry
    2. Entering an Addendum
    3. Entering a Clarification
  3. Omissions on Medication, Treatment Records, Graphic and Other Flowsheets
  4. Documenting Care Provided by a Colleague
  5. Patient Amendments to their Record
DOCUMENTATION IN THE LONG TERM CARE RECORD - Updated 6/09
1. Documentation Content in a Long Term Care Record - Updated 6/09
  1. Admission Record
2. Assessments - Updated 6/09
  1. Integrating Assessments with RAI Process
  2. Types of Assessments and Requirements
    1. Preadmission Assessment
    2. Admission Assessment
    3. Fall Assessment
    4. Skin Assessment
    5. Bowel and Bladder Assessment
    6. Physical Restraint Assessment
    7. Self-Administration of Medication
    8. Nutrition Assessment
    9. Activities/Recreation/Leisure Interest Assessment
    10. Social Service
    11. Mental and Psychosocial Functioning
    12. Restorative/Rehab Nursing Assessment
    13. Rehabilitation Services
3. Resident Assessment Instrument (RAI) – MDS and RAPS - Updated 6/09
4. Care Plan - Updated 6/09
  1. Timeliness
  2. Care Conference
  3. Admission/Interim Care Plan
  4. Integrating Acute Problems Into the Care Plan
  5. Timeliness of Completion of Care Plan
  6. Authenticating Changes to Care Plan
5. Narrative Charting and Summaries - Updated 6/09
  1. Admission/Readmission Note
  2. Content of Narrative Charting
  3. Monthly Summary Charting
  4. Integrated vs. Disciplinary Progress Notes
6. Medicare Documentation - Updated 10/08
  1. Skilled Nursing/Therapy Charting
  2. Supporting Documentation for the MDS
  3. Therapy Treatment Time
  4. ADL Charting
  5. Mood and Behavior Documentation
  6. Hospital Documentation
  7. Medicare Certification/Recertification
7. Rehabilitative Therapy Documentation – On-Hold
8. Physician Documentation - Updated 10/08
  1. Physician Progress Notes
  2. Dictated Progress Notes
  3. NP/PA Documentation
  4. History and Physical
  5. Other Professional and Consultation Records/Notes
  6. Documenting Resident Diagnoses
  7. Final Progress Note/Discharge Note
9. Physician Orders
  1. Admission Orders
  2. Content of an Order
  3. Physician Order Recaps/Renewals
  4. Telephone Orders
  5. Fax Orders
  6. Standing Order Policies
  7. Authentication/Obtaining Signatures
  8. Transcription of Orders and Noting Orders
  9. Contacting the Physician to Obtain an Order
  10. Discontinuing an Order When a New Order is Obtained
  11. Updating/Changing Physician Order Recaps/Renewals After They Have Been Signed
  12. Processing Physician Orders After Hospitalization "Resume all Previous Orders"
  13. Verification of Hospital Orders with Attending Physician
  14. Accepting Orders From a NP/PA
  15. Accepting Orders from Specialists or Consultants
10. Pharmacy Drug Review
11. Antipsychotic Drug Therapy - Updated 12/08
  1. Dose Reduction Schedules and Documentation
12. Medication and Treatment Records - Updated 10/08
  1. Starting new Medication/Treatment Records Upon Readmission/Hospital Return
13. Flow Sheets/Flow Records - Updated 10/08
  1. Service Delivery Records
  2. Other Clinical Flow Records
14. Labs and Special Reports - Updated 10/08
15. Consents, Acknowledgements and Notices - Updated 12/08
  1. Informed Consent for Use of a Restraint
  2. Consent, Notice and Authorization to Use/Release Clinical Records
  3. Notice of Bedhold Policy and Readmission
  4. Notice of Legal Rights and Services
  5. Notice Before Transfer
  6. Notice Prior to Change of Room or Roommate
16. Advance Directives - Updated 12/08
  1. DNR Order vs. Advance Directives
17. Discharge Documentation - Updated 12/08
  1. Discharge Order
  2. Discharge Note
  3. Discharge Summary
  4. Transfer Form
  5. Physician’s Discharge Summary vs. Discharge Record
CHECKLIST OF HIM POLICY AND PROCEDURES - Updated 6/09