Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Health Information Management Technology: An Applied Approach Third Edition Chapter 3: Content and Structure of the Health Record © 2011 Introduction • Electronic Health Record (EHR) o Most widely used term o Record is available electronically allowing communication across providers and permitting real-time decision making o Efficient reporting mechanisms • Other terms used o Electronic medical record o Computer-based patient record © 2011 Content of the Health Record • Record is used for: o Planning and managing diagnostic, therapeutic, and nursing services o Evaluating the adequacy and appropriateness of care o Substantiating reimbursement claims o Protecting the legal interests of the patient, the healthcare providers, and the healthcare organization © 2011 Content of the Health Record • Health record is means of communication between healthcare providers • Health record is used in research, public health, educational, and organizational activities o Organizational activities includes performance activities, risk management, strategic planning © 2011 Content of the Health Record • Clinical data o Documents medical condition, diagnoses, procedures, and treatment • Administrative data o Demographic and financial information o Consents and authorization © 2011 Standards for Documentation • Facility specific standards o Policies and procedures o Medical staff bylaws, and rules and regulations • Licensure requirements • Government reimbursement programs o Such as Medicare Conditions of Participation • Accreditation standards o Such as Joint Commission © 2011 Standards for Documentation • These standards address o Content o Time limits for completion • Data sets also determine content o Example: Uniform Ambulatory Care Data Set © 2011 Basic Acute Care Documentation • Content based on documentation standards © 2011 Clinical Data • Collection begins before admission • Admitting diagnosis © 2011 Medical History • Current complaints and symptoms • Past medical, personal, and family history © 2011 Physical Examination Report • Physician’s assessment of patient’s current health status • Addresses major organ systems © 2011 Diagnostic and Therapeutic Orders • Physician orders o Admission orders o Discharge orders • Orders should be: o Legible o Date o Signed by physician © 2011 Diagnostic and Therapeutic Orders • Standing orders • Verbal orders © 2011 Clinical Observation • Progress notes o Documented by physicians, nurses, other healthcare providers o Chronological report of patient’s condition and response to treatment © 2011 Physician Notes • Who can document is defined in medical staff rules and regulations • Specialty notes o Preanesthesia o Postanesthesia o Summary statement (death) © 2011 Nursing and Allied Health Notes and Assessments • • • • • • • Admission nursing assessment Care plan Vital signs Medications Special interventions such as restraints Allied health assessments Documentation of treatment by allied health professionals © 2011 Reports of Diagnostic and Therapeutic Procedures • Diagnostic reports o Lab tests o Pathology examinations o Radiological scans and images o Monitors and tracings of body functions © 2011 Procedure and Surgical Documentation • Preoperative notes by anesthesiologist and surgeon • Procedure recorded • Anesthesia record • Operative report • Postanesthesia (recovery room) • Pathology report © 2011 Patient Consent Forms • • • • Must be signed by patient Implied consent Expressed consent Physician must ensure patient understands procedure, alternative treatments, risks, complications, and benefits © 2011 Anesthesia Report • Notes preoperative medication o Dose o Method of administration o Duration of administration o Vital signs o Preanesthesia © 2011 Procedure and Operative Reports • • • • Preoperative and post operative diagnoses Description of procedures performed Description of all normal and abnormal findings Description of the patient’s medical condition before, during, and after the operation • Estimated blood loss • Description of any specimens removed © 2011 Procedure and Operative Reports • Description of any unique or unusual events during the course of the surgery • Names of the surgeons and their assistants • Date and duration of the surgery © 2011 Recovery Room Report • Documents monitoring of patient in recovery room o Postanesthesia notes o Patient’s condition o Nurses notes o Vital signs o Intravenous fluids © 2011 Pathology Report • Description of tissue o Macroscopic o Microscopic • Full written report © 2011 Consultation Reports • Documents the clinical opinion of physician other than attending physician • Requested by attending physician © 2011 Discharge Summary • Concise account of patient’s illness, course of treatment, response to treatment and condition at time of discharge • In a paper-based record a discharge note is acceptable IF: o Uncomplicated stay of less than 48 hours o Uncomplicated delivery of normal newborn © 2011 Patient Instructions and Transfer Records • Instructions given to patient at time of discharge • Transfer record is brief review of hospitalization © 2011 Autopsy Report • Description of examination of patient’s body after death • Performed when there is question about cause of death • Must have consent for autopsy © 2011 Obstetrics and Newborn Documentation • Obstetric record o Prenatal record from physician office o Admission evaluation o Record of labor o Delivery record • Newborn record o Birth history o Newborn identification o Physical exam © 2011 Administrative Data • Includes demographic and financial information o Demographics is study of the statistical characteristics of human population • Name • Address • Phone number o Financial • Insurance company • Policy numbers © 2011 Other Administrative Information • May also find: o Property lists o Birth certificate o Death certificate © 2011 Consents, Authorizations, and Acknowledgements • Consent to treat • Notice of privacy practices • Authorizations related to the release and disclosure of confidential health information © 2011 Advanced Directives • Written document that names legal representative for healthcare purposes o Living wills o Durable power of attorney • Patient Self-Determination act o Policies where patients can accept for refuse medical treatment o Patients notified of rights in making treatment decisions o Document presents of advance directive © 2011 Acknowledgement of Patient’s rights • Medicare Conditions of Participation give patient right to: o Know who is providing treatment o Confidentiality o Receive information about treatment o Refuse treatment o Participate in care planning o Be safe from abusive treatment © 2011 Specialized Health Record Documentation • Emergency Care Documentation o Documents presenting problems o Diagnostic and therapeutic services © 2011 Emergency Care Documentation • • • • • • • Patient identification Time and means of arrival Pertinent history Emergency care given prior to arrival Diagnostic and therapeutic orders Clinical observations Reports and results of procedures and tests © 2011 Emergency Care Documentation • Diagnostic impression • Medications administered • Conclusions o Final disposition o Condition on discharge/transfer o Patient instructions o Documentation of patient leaving against medical advise (where appropriate) © 2011 Ambulatory Care Documentation • Includes physician offices, clinics, hospital outpatient, neighborhood health, public health, industrial health, and urgent care settings © 2011 Ambulatory Care Documentation • • • • • • • Registration forms Problem lists Medication lists History and physicals Progress notes Results of consultations Diagnostic test results © 2011 Ambulatory Care Documentation • Flow sheets (pediatric growth charts, immunization records, etc.) • Copies of records from previous hospitalizations • Correspondence • Consents to disclose information • Advanced directives © 2011 Problem List • List of significant current and past illnesses and conditions and procedures © 2011 Obstetric/Gynecologic Care Documentation • Medical history o Reason for visit o Health status o Dietary/nutritional assessment o Physical fitness and exercise status o Tobacco, alcohol, and drug usage o History of abuse or neglect o Sexual practices including high-risk behaviors and method of contraception © 2011 Obstetric/Gynecologic Care Documentation • Physical examination • Lab tests © 2011 Pediatric Care Documentation • • • • • • Past medical history Birth history Nutritional history Personal, social, and family history Growth and development record Review of systems © 2011 Ambulatory Surgical Care Documentation • Free standing ambulatory surgery centers • Records are similar to hospital-based surgery department © 2011 Ambulatory Surgical Care Documentation • Patient identification • Significant medical history and the results of the physical examination • Preoperative studies • Findings and techniques of the operation • Allergies and abnormal drug reactions • Record of anesthesia administration • Documentation of informed consent • Discharge diagnosis © 2011 Long Term Documentation • • • • • • Skilled nursing facilities Subacute care facilities Nursing facilities Intermediate care facilities ICFs for the mentally retarded Assisted-living facilities © 2011 Long Term Documentation • Based on ongoing assessments and reassessments of patient’s needs • Interdisciplinary team develops care plan • Resident Assessment Instrument: care plan • Minimum Data Set for Long Term Care © 2011 Long Term Documentation • Identification and admission information • Personal property list, including furniture and electronics • History and physical and hospital records • Advanced directives, bill of rights, and other legal records • Clinical assessments • RAI/MDS and care plan © 2011 Long Term Documentation • • • • Physician orders Physician’s progress notes/consultations Nursing or interdisciplinary notes Medication and records of other monitors, including administration of restraints • Laboratory, radiology, and special reports • Rehabilitation therapy notes © 2011 Long Term Documentation • Social services, nutritional services, and activities documentation • Discharge documentation © 2011 Home Health Care Documentation • Provide medical and nonmedical services in patient’s home • Outcomes and Assessment Information Set (OASIS) o Completed periodically o Basis of reimbursement for Medicare © 2011 Home Health Documentation • • • • • • • • Initial database/demographics and serve agreement Certification and plan of treatment Physician orders Documentation per visit OASIS, plan of care, and case conference notes Consents and other legal documents Referral or transfer information Discharge summaries © 2011 Hospice Care Documentation • Care can be provided: o In patient’s home o Hospitals o Long term care facilities o Separate free standing facilities • Provide palliative care for the terminally ill and support for family • Care plan documented every 30 days © 2011 Behavioral Healthcare Documentation • Care provided in inpatient hospitals, outpatient clinics, physician offices, rehabilitation programs, and community mental health programs • Documentation varies by setting © 2011 Inpatient Behavioral Healthcare Documentation • • • • • • • Identification Source of referral Reason for referral Patient’s legal status Consents Admitting psychiatric diagnoses Psychiatric history © 2011 Inpatient Behavioral Healthcare Documentation • Record of the complete patient assessments, including complaints of others regarding the patient as well as the patient’s comments • Medical history, report of physical examination, and record of all mediations prescribed • Provisional diagnoses (psychiatric and physical) • Written individualized treatment plans © 2011 Inpatient Behavioral Healthcare Documentation • Documentation of the course of treatment and all evaluations and examinations • Multidisciplinary progress notes related to the goals and objectives outlined in the treatment plan • Appropriate documentation related to special treatment procedures • Updates to treatment plan as result of assessments detailed in progress notes © 2011 Inpatient Behavioral Healthcare Documentation • Multidisciplinary case conferences and consultation notes • Information on any unusual occurrences such as treatment complications, accidents, and injuries • Correspondence including letters and telephone notes • Discharge or termination summary © 2011 Inpatient Behavioral Healthcare Documentation • Plan for follow-up care and documentation of its implementation • Individual aftercare or post-treatment plan © 2011 Rehabilitation Services Documentation • Focus of setting is to increase a patient’s ability to function • Documentation varies by type of setting: inpatient, outpatient, special programs • Patient assessment instrument (PAI) o Completed on admission and at discharge © 2011 Rehabilitation Services Documentation • • • • • Identification data Pertinent history, influencing functional history Diagnosis of disability/functional diagnosis Rehabilitation problems, goals, and prognosis Reports of assessments and individual program planning © 2011 Rehabilitation Services Documentation • Reports from referring sources and service referrals • Reports from outside consultations and laboratory, radiology, orthotic and prosthetic services • Designation of a manager for the patient’s program • Evidence of the patient or families participation in decision making © 2011 Rehabilitation Services Documentation • • • • • • Evaluation reports from each service Reports of staff conferences Patient’s total program plan Plans from each service Signed and dated service and progress reports Correspondence pertinent to patient © 2011 Rehabilitation Services Documentation • Release forms • Discharge report • Follow-up report © 2011 Documentation of Services Provided in Correction Facilities • • • • • Provide healthcare to those incarcerated Begins at initial intake process Documents care provided Record may transfer with patient Examples of record content includes: o History and physical o Care provided o Progress notes © 2011 End-Stage Renal Disease Service Documentation • Dialysis provided to patients with kidney disease • Documentation includes o Patient rights o Interdisciplinary treatment assessment o Plan of care o Progress notes o Lab tests o Discharge summary o Consents © 2011 End-Stage Renal Disease Service Documentation • Special emphasis is on: o Nutritional o Anemia o Vascular access o Transplant o Rehabilitation status o Social service interventions o Dialysis dosages © 2011 Documentation Standards • Documentation impacts quality of direct patient care. • Primary communication between caregivers • Used for continuing care • Evidence that care and treatment occurred © 2011 Basic Principles of Health Record Documentation • Policies to ensure uniformity of both the content and format of health record • Health record should be organized systematically to facilitate data retrieval and compilation • Only individuals authorized in policies can document in health record • Policies and medical staff bylaws define who can receive and transcribe verbal orders © 2011 Basic Principles of Health Record Documentation • Health record entries are documented at the time service is provided • Authors of entries should be clearly identified • Only abbreviations and symbols approved by organization and medical staff rules and regulations can be documented in health record • All entries are permanent © 2011 Basic Principles of Health Record Documentation • Errors are corrected as follows: o Single line drawn in ink through incorrect entry o Print word error at top of entry along with signature (or initials) o Document date, time and reason for change o Record correct information o Must be able to read error o Late entries must be labeled as such © 2011 Basic Principles of Health Record Documentation • Corrections or information added by patient must be inserted as addendum o No change to original entry • HIM department should have policies and procedures related to qualitative and qualitative analysis of health records © 2011 Standards for Health Record Documentation • State regulating Agencies o Regulations on how a healthcare organization operates o Each state is different o Must comply with regulations to be licensed © 2011 Medicare and Medicaid Programs • Administered by Centers for Medicare and Medicaid Services • Medicare Conditions of Participation • Deemed status • Medicaid program varies by state © 2011 Accreditation Organizations • Public recognition through accreditation • Must meet patient care and other standards for high-quality care • Periodic surveys to determine compliance with surveys © 2011 Joint Commission • Accredits a number of different settings • Unannounced surveys • Annual submission of Periodic Performance review • Standards for documentation • Prohibited abbreviation list © 2011 American Osteopathic Association • Accredits osteopathic organizations © 2011 Accreditation Association for Ambulatory Health Care • Accredits ambulatory settings • Documentation standards emphasize summaries for enhancing continuity of care © 2011 Commission on Accreditation of Rehabilitation Facilities • Accredits rehabilitation programs and services © 2011 National Committee for Quality Assurance • Accredit managed care organizations © 2011 Other Accrediting Groups • A number of specialty accrediting groups exist • DNV o Began accreditation in United States in 2008 o Gaining acceptance © 2011 Format of Health Record • Paper-based • Electronic © 2011 Paper-Based Health Record • Specific guidelines on how health records are to be arranged • Limitations such as inability to customize • Three formats: o Source-oriented o Problem-oriented o Integrated © 2011 Source Oriented • Documents are grouped together based on point of origin • Reports in each section may be in chronological or reverse chronological order © 2011 Problem-Oriented Health Records • Itemized list of patient’s past and present social, psychological, and medical problems • Each problem is indexed with unique number • Three sections o Database o Initial care plan o Progress notes © 2011 Database Contains • • • • • • Chief complaint Present illness Social history Medical history Physical examination Diagnostic test results © 2011 Initial Plan • Roadmap for addressing each problem • Plans are numbered to correspond to the problem they address © 2011 Progress Notes • Documents problems treated and how patient is responding to treatment • Progress note is labeled with the unique number assigned to problem • SOAP format o Subjective o Objective o Assessment o Plan © 2011 Integrated Health Records • Documentation from various sources is intermingled and follows strict chronological order © 2011 Future of Paper-Based Health Records • Today’s paper-based records are improved but still have weaknesses o Difficult to update o Availability o Susceptible to damage from water, fire, and use • Electronic records are recommended © 2011 Electronic Health Records • Office of the National Coordinator for Health Information Technology definitions o Electronic medical record: an electronic record of healthrelated information on an individual that can be created, gathered, managed, and consulted by authorized clinician and staff within one health organization o Electronic health record: an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization © 2011 Electronic Health Record Core Capabilities • • • • • • • • Health information and data Results management Order entry and management Decision support Electronic communication and connectivity Patient support Administrative processes Reporting and population health management © 2011 Electronic Health Record Technologies • Databases and database management systems o Centralized record o Distributed record o Mix of centralized and distributed record © 2011 Data Input • • • • • • • Transcription Continuous voice recognition Optical characters readers Bar code readers Document imaging Automated templates Structured data entry © 2011 Image Processing and Storage • Combine health record text files with diagnostic imaging files • Advantages o Lost files are rare o More than one person can view record at the same time o Transfer images to remote locations quickly © 2011 Text Processing and Data Retrieval • Improved text searching and retrieval due to indexing • Identify key words and phrases in textual data © 2011 System Communications and Networks • Information can be shared through o Integrated delivery system o Regional health information organizations o Health information exchanges • Must mange communication technologies and balance needs of multiple users • Lack of standards © 2011 Transitions in Record Practices • Challenges include: o Changes in workflow and processes o Coordination of record sharing • Must maintain legal and regulatory compliance • Record content and documentation standards apply to any format • Must address timely capture and display of information © 2011 Transitions in Record Practices • • • • Must create edit checks Evaluate records for completeness Control access to records Address retention, backups, and destruction © 2011 Hybrid Health Record • AHIMA e-HIM Workgroup definition: o A hybrid health record is a system with functional components that: • Include both paper and electronic documents • Use both manual and electronic processes © 2011 Transitions in Record Practices • Challenges of hybrid record o Must manage both electronic and paper records o Must define what constitutes a record o Must manage multiple versions © 2011 Personal Health Record • National Alliance for Health Information Technology’s definition: o An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn form multiple sources while being managed, shared, and controlled by the individual © 2011 Personal Health Records • AHIMA eHIM Personal Health Record Work Group’s minimum common data elements: o o o o o o o o o o Personal demographic information General medical information Allergies and drug sensitivities Conditions Hospitalizations Surgeries Medications Immunizations Clinical tests Pregnancy history © 2011 Additional Information • Information from providers • Genetic information • Personal, family, occupational, and environmental history • Health plans and goals • Health status of individual © 2011 Additional Information • Documentation of choices in relation to organization donation, durable power of attorney, and advanced directives • Charges paid for services and products • Health insurance information • Provider directory © 2011