HI125: Healthcare Delivery & Information Management

1. HI125: Healthcare Delivery & Information Management Instructor: Karen Tepe Week 3 Seminar

2. OutstandingQuestions?

3. Unit 3 Topic The importance of timeliness and the required documents and elements in the acute care record.

4. What is the medical record Business record for the patient encounter Documentation of all health care services provided to the patient Repository of information to support treatment and diagnosis Unique identifier (e.g. MRN) Must be accurate and consistent Provide for continuity of care Must be confidential and secure Must be federal and state regulations “If it wasn’t documented, it wasn’t done.”

5. Secondary Purposes Evaluating quality of care Providing information to third party payers for reimbursement Legal purposes (for patient, facility, and providers) Providing data for clinical research Education Public policy making Health care statistics

6. Types of Records Inpatient Record Outpatient Record (Ambulatory Care) Emergency Visit Clinic Visits Outpatient Surgery Ancillary Services Physician Office Record Shadow Record Archived Record Varies from state to state and type of record CMS requires 5 years for hospitals, LT care, HHC and specialized providers AHA recommends 5 years

7. Formats of Records Paper record (manual) Electronic medical record (EMR, EHR) Hybrid medical record Imaging systems Microfilm Microfiche CD-Rom/DVD

8. Record Ownership The medical record is the property of the facility in which it was generated (e.g. hospital, provider office) The patient has the right to obtain access to his/her medical record (e.g. Release of Information)

9. Documentation Requirements Only authorized individuals document in the medical recor – should have the authority and right to document Entries into the medical record are appropriately authenticated Entries should be authenticated by the author Include first initial, last name and title/credential Countersignatures, as required by state law Documentation is timely As soon as possible after care is provided H&P within 7 days of admission or 24 hours post admission Verbal orders authenticated within 24 hours Complete within 30 days post discharge Legible Abbreviations

10. Deficient vs Delinquent HIM’s Role: monitor adherence to documentation requirements Record Assembly (e.g. Universal Assembly, chronologic) Quantitative Analysis – review for completeness Qualitative Analysis – review for inconsistencies Concurrent Analysis – patient is in-house Statistical Analysis – abstracting patient information/data Complete within 30 days Deficiency reports Governing body

11. Questions?