HIM 1101 SPSU Health Record Content and Documentation Discussion and Case Study
Sample Answer for HIM 1101 SPSU Health Record Content and Documentation Discussion and Case Study Included After Question
Description
Discussion 4.1: Outside Influence on Healthcare Documentation
Guidelines
Please make sure your discussion posts include all of the items below:
Summarize what influence outside entities have on documentation standards in healthcare.
Note: your initial summary post should be one or two paragraphs in length (a paragraph is at least 3 sentences in length).
SPC Real World Case 4.1: Anywhere Hospital
Real World Case 4.120 POINTS
For this activity, you will review the Real World Case 4.1 below. Conduct an analysis of the situation and summarize how you would have addressed the issues by answering the questions below.
Analyze Real World Case 4.1:
When Anywhere Hospital began developing its EHR the EHR task force set out to develop an EHR that will serve as the organization’s legal health record. The unofficial goal of the EHR task force was to compile all available health information into a single system and provide the means to deliver the needed administrative and clinical data instantaneously to end users when needed. Large volume of information, overcrowded computer screens, and lack of uniform structure soon proved overwhelming for the system’s end users. Their feedback called for useful and needed health record information formatted in a usable structure.
- In response to end-user frustration, the EHR task force took a hard look at the captured information and how that information was then presented to the end user. The task force considered the following questions:
- How is the health information captured, formatted, and structured into one system when pulling from many sources?
- How long is health information retained?
What information is purged from the system and when is it purged?
What health information is archived? Is there any information needed to be kept permanently?
How much control should end users have over the information they are allowed to access?
Read the case study above and then answer the following questions:
What is the role of the EHR task force?
Who are the users of the EHR? What do these users need to be able to do in the EHR?
How does the legal health record apply to the EHR?
Guidelines
Before you submit your Real-World Case Study written responses:
Ensure all of the Real World Case Study 4.1 questions are answered thoroughly.
View the Critical Thinking Assignment Rubric (20 points) for the grading criteria.
Then, finally, complete and submit your answers in the Quiz Tool.
Please Note: Each question is worth 6.66 points for a total of 20 points.
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SPC Real World Case 4.2: Anywhere Hospital Copy Paste Function
Real World Case 4.220 POINTS
For this activity, you will review the Real World Case 4.2 in your textbook. Conduct an analysis of the situation and summarize how you would have addressed the issues by answering the questions below.
Analyze Real World Case 4.2. Read the case study and then answer the following questions.
What should be considered when deciding whether or not to use the copy and paste functionality?
What controls might be put in place related to the copy and paste functionality?
What alternatives to the copy and paste functionality are available?
Health Information Management Technology: An Applied Approach Sixth Edition Chapter 4: Health Record Content and Documentation ahima.org ahima.org © 2020 AHIMA © 2019 © 2020 American Health Information Management Association Documentation • Recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregivers • Allows for the telling and retelling of events ahima.org © 2020 AHIMA © 2019 Impact of Poor Documentation • Poor outcomes • Issues with patient care • Issues with the accuracy of diagnosis and procedure codes • Errors on healthcare claim ahima.org © 2020 AHIMA © 2019 Documentation Standards • Describes those principles, codes, beliefs, guidelines, and regulations that guide healthcare documentation. • Dictates how healthcare providers should document the treatment and services within the health record. ahima.org © 2020 AHIMA © 2019 Standard Set of principles, codes, beliefs, guidelines, and regulations that have been vetted and agreed upon by an individual or a group of individuals. ahima.org © 2020 AHIMA © 2019 Documentation Standard • Standard that controls health record documentation ahima.org © 2020 AHIMA © 2019 Documentation Standards and E H R s • E H R s and paper-based health records typically have the same basic documentation standards • Templates ahima.org © 2020 AHIMA © 2019 Standards 1 Documentation standards have grown in complexity and detail over time Focus on • Patient care quality • Appropriate reimbursement • Prevention of fraud and abuse ahima.org © 2020 AHIMA © 2019 Standards 2 Documentation standards vary upon the type of health record Multiple sources of documentation standards: • Insurance company or payers • Government regulatory agencies • Licensing boards • Accrediting bodies • Facility policies and procedures • Medical staff bylaws ahima.org © 2020 AHIMA © 2019 Goals of Documentation Standards • Ensure complete health record and accurately reflects the treatment provided to the patient • Drive appropriate reimbursement through accurate code capture ahima.org © 2020 AHIMA © 2019 Medical Staff Bylaws 1 • Standards governing the practice of medical staff members • Voted on by the organized medical staff and the medical staff executive committee • Approved by the healthcare organization’s board of directors • Used to enforce quality of care ahima.org © 2020 AHIMA © 2019 Medical Staff Bylaws 2 Required by • Licensure organizations • Accreditation organization • Federal and state regulatory agencies Each organization mandates content Medical staff bylaws will vary slightly from one organization to another ahima.org © 2020 AHIMA © 2019 Medical Staff • Physicians and nonphysician providers who have privileges to practice medicine at a particular healthcare organization • May or may not be employed by the healthcare organization • Medical staff are subject to the medical staff bylaws ahima.org © 2020 AHIMA © 2019 Medical Staff Privileges Specific services and procedures that the medical staff member is deemed qualified to perform, at a particular healthcare provider organization ahima.org © 2020 AHIMA © 2019 Accreditation 1 • A voluntary process • Periodical evaluation against preestablished written criteria • Healthcare organizations measure their own compliance with standards • Enhances the reputation of the organization in the eyes of the patient • Differs by the type of program or service ahima.org © 2020 AHIMA © 2019 Accreditation 2 Healthcare organizations that are accredited by an approved accreditation organization are exempt from routine state survey agencies ahima.org © 2020 AHIMA © 2019 Accreditation Organization Must go through its own CMS review to obtain deemed status • Evaluates healthcare organizations for compliance with C o P s and CFCs ahima.org © 2020 AHIMA © 2019 Joint Commission 1 • Accredits wide variety of healthcare organizations • Continuously updates survey processes • Surveys clinical and operational components • Provides education to healthcare organizations related to compliance ahima.org © 2020 AHIMA © 2019 Joint Commission 2 Provides accreditation for: • Ambulatory healthcare • Behavioral health • Critical access hospital • Homecare • Hospital ahima.org © 2020 AHIMA © 2019 • Laboratory • Nursing care centers • Physician offices • Office-based surgery centers Other Accreditation Organizations • Healthcare Facilities Accreditation Program • Commission on Accreditation of Rehabilitation Facilities • Accreditation Association for Ambulatory Healthcare ahima.org © 2020 AHIMA © 2019 State Statutes • Legislation written and approved by a state legislature and then signed into law by the state’s governor • Addresses the documentation requirements for specific types of health records ahima.org © 2020 AHIMA © 2019 Legal Health Record 1 Documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information • Content varies from provider organization to another ahima.org © 2020 AHIMA © 2019 Legal Health Record 2 Policies and procedures should be established to defining legal health record ahima.org © 2020 AHIMA © 2019 General Documentation Guidelines 1 • Apply to all categories of health records • Every healthcare organization should have policies • Organized systematically to facilitate data retrieval and compilation ahima.org © 2020 AHIMA © 2019 General Documentation Guidelines 2 • Only individuals authorized by the organization’s policies should be allowed to enter documentation in the health record. • Organizational policy or medical staff rules and regulations should specify who may receive and transcribe verbal physician’s orders. ahima.org © 2020 AHIMA © 2019 General Documentation Guidelines 3 • Health record entries should be documented at the time the services they describe are rendered. • Authors of entries should be clearly identified in the record. • Only abbreviations and symbols approved by the organization or medical staff rules and regulations should be used in the health record. ahima.org © 2020 AHIMA © 2019 General Documentation Guidelines 4 All entries in the health record should be permanent. Any corrections or information added to the record by the patient should be inserted as an addendum • No changes should be made in the original entries in the record • Information added to the health record by the patient should be clearly identified as an addendum ahima.org © 2020 AHIMA © 2019 CMS Documentation Requirements Entries must be • Legible • Complete • Dated and timed • Author identified • Authenticated in written or electronic form ahima.org © 2020 AHIMA © 2019 Authentication Identifying the source of health record entries • Written signature • Initials • Electronic signature CMS requires controls to prevent any changes from being made to the health record after the entries have been authenticated ahima.org © 2020 AHIMA © 2019 Auto-Authentication When a physician or other care provider authenticates an entry without reviewing ahima.org © 2020 AHIMA © 2019 Documentation by Setting 1 Health record information consists of two types regardless of setting • Clinical • Administrative ahima.org © 2020 AHIMA © 2019 Documentation by Setting 2 • Must have health record for each person • Content varies by setting • Contains clinical and administrative data ahima.org © 2020 AHIMA © 2019 Inpatient Health Record • Patient stays overnight • Medical or surgical • Most complex health record ahima.org © 2020 AHIMA © 2019 Inpatient Health Record—Clinical Medical history • Current condition • Past medical history • Personal history • Family history • Chief complaint ahima.org © 2020 AHIMA © 2019 1 Inpatient Health Record—Clinical 2 Physical exam • Physician assessment Diagnostic and therapeutic procedure order • Physician order • Standing order ahima.org © 2020 AHIMA © 2019 Inpatient Health Record—Clinical Clinical observation • Progress note • Integrated health record • Summary statement (death) Care plan ahima.org © 2020 AHIMA © 2019 3 Inpatient Health Record—Clinical 4 Autopsy report Vital signs Flow charts Diagnostic and therapeutic procedure reports • Lab, pathology, and radiology and other tests/treatments ahima.org © 2020 AHIMA © 2019 Inpatient Health Record—Clinical • Anesthesia report • Operative report • Recover room report • Pathology report • Consultation report ahima.org © 2020 AHIMA © 2019 5 Inpatient Health Record—Clinical 6 Discharge summary • Overview of encounter • Not required for hospitalization less than 48 hours, uncomplicated delivery or newborn Patient instructions Transfer records ahima.org © 2020 AHIMA © 2019 Inpatient Health Record—Administrative Patient registration • Demographics ahima.org © 2020 AHIMA © 2019 1 Special Health Records Some health records have unique requirements because of the specialized services provided ahima.org © 2020 AHIMA © 2019 Obstetric and Newborn Health Record Obstetric • Prenatal • Labor and delivery Newborn • APGAR ahima.org © 2020 AHIMA © 2019 Ambulatory Health Record – General • Demographics • Problem list ahima.org © 2020 AHIMA © 2019 Ambulatory Surgery Record • Similar to inpatient surgical health record • Follow-up post surgery ahima.org © 2020 AHIMA © 2019 Ancillary Departments Tests and procedures ahima.org © 2020 AHIMA © 2019 Physician Office Record • Preventive care • Minor illnesses and injuries ahima.org © 2020 AHIMA © 2019 Long-Term Care Ongoing assessments Care plan • Resident Assessment instrument • Minimum Data Set for Long-Term Care ahima.org © 2020 AHIMA © 2019 Rehabilitation Minimum Data Set, Version 3 (MDS 3.0) Resident Assessment Instrument • 5-Day Assessment (mandatory) • Interim Payment Assessment (optional) • Discharge Assessment (mandatory) ahima.org © 2020 AHIMA © 2019 Behavioral Health • Includes similar content • Family and caregiver input is documented ahima.org © 2020 AHIMA © 2019 Home Health • Treatment plan • Health assessment • Problem list • Treatment goals • Interventions and outcomes ahima.org © 2020 AHIMA © 2019 Federal and State Initiatives on Documentation Trends are to focus on • Quality of care provided • Value-based care Reimbursement provide incentives for quality of care MACRA Core Measures ahima.org © 2020 AHIMA © 2019 Paper Health Record—Format Source-oriented health record Universal chart order Integrated health record Problem-orientated medical record • Subjective, Objective, Assessment, Plan (SOAP) ahima.org © 2020 AHIMA © 2019 Electronic Health Record • Point-of-care documentation • Documentation captured electronically ahima.org © 2020 AHIMA © 2019 Web-Based Document Imaging • Capture, digitize, integrate, store, and retrieve paper-based health record documentation • Organizes and assembles the paper-based health record documentation, and controls the versioning, access, and search capabilities of the documentation ahima.org © 2020 AHIMA © 2019 Role of Healthcare Professionals in Documentation 1 Physicians • Document appropriately so that quality care can be rendered and that appropriate reimbursement can occur ahima.org © 2020 AHIMA © 2019 Role of Healthcare Professionals in Documentation 2 Nurses • Documentation varies by licensing and regulatory requirements, setting, and internal policy and procedures ahima.org © 2020 AHIMA © 2019 Role of Healthcare Professionals in Documentation 3 Allied Health Professionals • Many follow treatment plan developed by the patient’s physician or a therapist or technologist • Documents treatment and patient’s response ahima.org © 2020 AHIMA © 2019 H I M and Documentation • Plays vital and different roles in the overall governance of health record information • Manages many aspects of the health record and its content • Used in coding, billing, and other H I M functions ahima.org © 2020 AHIMA © 2019 H I M Roles • Clinical documentation integrity coordinator • Analyst ahima.org © 2020 AHIMA © 2019