Transcript Content of the Health Record

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
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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
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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
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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
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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
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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
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Basic Acute Care Documentation
• Content based on documentation standards
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Clinical Data
• Collection begins before admission
• Admitting diagnosis
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Medical History
• Current complaints and symptoms
• Past medical, personal, and family history
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Physical Examination Report
• Physician’s assessment of patient’s current health
status
• Addresses major organ systems
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Diagnostic and Therapeutic Orders
• Physician orders
o Admission orders
o Discharge orders
• Orders should be:
o Legible
o Date
o Signed by physician
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Diagnostic and Therapeutic Orders
• Standing orders
• Verbal orders
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Clinical Observation
• Progress notes
o Documented by physicians, nurses, other healthcare
providers
o Chronological report of patient’s condition and
response to treatment
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Physician Notes
• Who can document is defined in medical staff
rules and regulations
• Specialty notes
o Preanesthesia
o Postanesthesia
o Summary statement (death)
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Nursing and Allied Health Notes and
Assessments
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Admission nursing assessment
Care plan
Vital signs
Medications
Special interventions such as restraints
Allied health assessments
Documentation of treatment by allied health
professionals
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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
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Procedure and Surgical Documentation
• Preoperative notes by anesthesiologist and
surgeon
• Procedure recorded
• Anesthesia record
• Operative report
• Postanesthesia (recovery room)
• Pathology report
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Patient Consent Forms
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Must be signed by patient
Implied consent
Expressed consent
Physician must ensure patient understands
procedure, alternative treatments, risks,
complications, and benefits
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Anesthesia Report
• Notes preoperative medication
o Dose
o Method of administration
o Duration of administration
o Vital signs
o Preanesthesia
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Procedure and Operative Reports
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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
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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
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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
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Pathology Report
• Description of tissue
o Macroscopic
o Microscopic
• Full written report
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Consultation Reports
• Documents the clinical opinion of physician
other than attending physician
• Requested by attending physician
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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
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Patient Instructions and Transfer Records
• Instructions given to patient at time of discharge
• Transfer record is brief review of hospitalization
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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
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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
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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
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Other Administrative Information
• May also find:
o Property lists
o Birth certificate
o Death certificate
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Consents, Authorizations, and
Acknowledgements
• Consent to treat
• Notice of privacy practices
• Authorizations related to the release and
disclosure of confidential health information
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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
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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
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Specialized Health Record Documentation
• Emergency Care Documentation
o Documents presenting problems
o Diagnostic and therapeutic services
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Emergency Care Documentation
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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
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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)
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Ambulatory Care Documentation
• Includes physician offices, clinics, hospital
outpatient, neighborhood health, public health,
industrial health, and urgent care settings
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Ambulatory Care Documentation
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Registration forms
Problem lists
Medication lists
History and physicals
Progress notes
Results of consultations
Diagnostic test results
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Ambulatory Care Documentation
• Flow sheets (pediatric growth charts,
immunization records, etc.)
• Copies of records from previous hospitalizations
• Correspondence
• Consents to disclose information
• Advanced directives
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Problem List
• List of significant current and past illnesses and
conditions and procedures
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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
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Obstetric/Gynecologic Care Documentation
• Physical examination
• Lab tests
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Pediatric Care Documentation
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Past medical history
Birth history
Nutritional history
Personal, social, and family history
Growth and development record
Review of systems
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Ambulatory Surgical Care Documentation
• Free standing ambulatory surgery centers
• Records are similar to hospital-based surgery
department
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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
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Long Term Documentation
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Skilled nursing facilities
Subacute care facilities
Nursing facilities
Intermediate care facilities
ICFs for the mentally retarded
Assisted-living facilities
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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
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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
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Long Term Documentation
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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
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Long Term Documentation
• Social services, nutritional services, and
activities documentation
• Discharge documentation
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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
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Home Health Documentation
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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
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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
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Behavioral Healthcare Documentation
• Care provided in inpatient hospitals, outpatient
clinics, physician offices, rehabilitation
programs, and community mental health
programs
• Documentation varies by setting
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Inpatient Behavioral Healthcare
Documentation
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Identification
Source of referral
Reason for referral
Patient’s legal status
Consents
Admitting psychiatric diagnoses
Psychiatric history
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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
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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
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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
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Inpatient Behavioral Healthcare
Documentation
• Plan for follow-up care and documentation of its
implementation
• Individual aftercare or post-treatment plan
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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
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Rehabilitation Services Documentation
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Identification data
Pertinent history, influencing functional history
Diagnosis of disability/functional diagnosis
Rehabilitation problems, goals, and prognosis
Reports of assessments and individual program
planning
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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
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Rehabilitation Services Documentation
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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
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Rehabilitation Services Documentation
• Release forms
• Discharge report
• Follow-up report
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Documentation of Services Provided in
Correction Facilities
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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
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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
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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
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Documentation Standards
• Documentation impacts quality of direct patient
care.
• Primary communication between caregivers
• Used for continuing care
• Evidence that care and treatment occurred
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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
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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
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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
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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
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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
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Medicare and Medicaid Programs
• Administered by Centers for Medicare and
Medicaid Services
• Medicare Conditions of Participation
• Deemed status
• Medicaid program varies by state
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Accreditation Organizations
• Public recognition through accreditation
• Must meet patient care and other standards for
high-quality care
• Periodic surveys to determine compliance with
surveys
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Joint Commission
• Accredits a number of different settings
• Unannounced surveys
• Annual submission of Periodic Performance
review
• Standards for documentation
• Prohibited abbreviation list
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American Osteopathic Association
• Accredits osteopathic organizations
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Accreditation Association for Ambulatory
Health Care
• Accredits ambulatory settings
• Documentation standards emphasize summaries
for enhancing continuity of care
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Commission on Accreditation of
Rehabilitation Facilities
• Accredits rehabilitation programs and services
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National Committee for Quality Assurance
• Accredit managed care organizations
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Other Accrediting Groups
• A number of specialty accrediting groups exist
• DNV
o Began accreditation in United States in 2008
o Gaining acceptance
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Format of Health Record
• Paper-based
• Electronic
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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
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Source Oriented
• Documents are grouped together based on point
of origin
• Reports in each section may be in chronological
or reverse chronological order
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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
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Database Contains
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Chief complaint
Present illness
Social history
Medical history
Physical examination
Diagnostic test results
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Initial Plan
• Roadmap for addressing each problem
• Plans are numbered to correspond to the problem
they address
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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
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Integrated Health Records
• Documentation from various sources is
intermingled and follows strict chronological
order
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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
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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
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Electronic Health Record Core Capabilities
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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
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Electronic Health Record Technologies
• Databases and database management systems
o Centralized record
o Distributed record
o Mix of centralized and distributed record
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Data Input
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Transcription
Continuous voice recognition
Optical characters readers
Bar code readers
Document imaging
Automated templates
Structured data entry
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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
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Text Processing and Data Retrieval
• Improved text searching and retrieval due to
indexing
• Identify key words and phrases in textual data
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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
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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
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Transitions in Record Practices
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Must create edit checks
Evaluate records for completeness
Control access to records
Address retention, backups, and destruction
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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
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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
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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
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Personal Health Records
• AHIMA eHIM Personal Health Record Work Group’s
minimum common data elements:
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Personal demographic information
General medical information
Allergies and drug sensitivities
Conditions
Hospitalizations
Surgeries
Medications
Immunizations
Clinical tests
Pregnancy history
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Additional Information
• Information from providers
• Genetic information
• Personal, family, occupational, and
environmental history
• Health plans and goals
• Health status of individual
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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
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