Health Information Management Technology: An Applied Approach Third Edition

1. Health Information Management Technology: An Applied ApproachThird Edition Chapter 3: Content and Structure of the Health Record

2. Introduction • Electronic Health Record (EHR) • Most widely used term • Record is available electronically allowing communication across providers and permitting real-time decision making • Efficient reporting mechanisms • Other terms used • Electronic medical record • Computer-based patient record

3. Content of the Health Record • Record is used for: • Planning and managing diagnostic, therapeutic, and nursing services • Evaluating the adequacy and appropriateness of care • Substantiating reimbursement claims • Protecting the legal interests of the patient, the healthcare providers, and the healthcare organization

4. 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 • Organizational activities includes performance activities, risk management, strategic planning

5. Content of the Health Record • Clinical data • Documents medical condition, diagnoses, procedures, and treatment • Administrative data • Demographic and financial information • Consents and authorization

6. Standards for Documentation • Facility specific standards • Policies and procedures • Medical staff bylaws, and rules and regulations • Licensure requirements • Government reimbursement programs • Such as Medicare Conditions of Participation • Accreditation standards • Such as Joint Commission

7. Standards for Documentation • These standards address • Content • Time limits for completion • Data sets also determine content • Example: Uniform Ambulatory Care Data Set

8. Basic Acute Care Documentation • Content based on documentation standards

9. Clinical Data • Collection begins before admission • Admitting diagnosis

10. Medical History • Current complaints and symptoms • Past medical, personal, and family history

11. Physical Examination Report • Physician’s assessment of patient’s current health status • Addresses major organ systems

12. Diagnostic and Therapeutic Orders • Physician orders • Admission orders • Discharge orders • Orders should be: • Legible • Date • Signed by physician

13. Diagnostic and Therapeutic Orders • Standing orders • Verbal orders

14. Clinical Observation • Progress notes • Documented by physicians, nurses, other healthcare providers • Chronological report of patient’s condition and response to treatment

15. Physician Notes • Who can document is defined in medical staff rules and regulations • Specialty notes • Preanesthesia • Postanesthesia • Summary statement (death)

16. 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

17. Reports of Diagnostic and Therapeutic Procedures • Diagnostic reports • Lab tests • Pathology examinations • Radiological scans and images • Monitors and tracings of body functions

18. Procedure and Surgical Documentation • Preoperative notes by anesthesiologist and surgeon • Procedure recorded • Anesthesia record • Operative report • Postanesthesia (recovery room) • Pathology report

19. Patient Consent Forms • Must be signed by patient • Implied consent • Expressed consent • Physician must ensure patient understands procedure, alternative treatments, risks, complications, and benefits

20. Anesthesia Report • Notes preoperative medication • Dose • Method of administration • Duration of administration • Vital signs • Preanesthesia

21. 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

22. 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

23. Recovery Room Report • Documents monitoring of patient in recovery room • Postanesthesia notes • Patient’s condition • Nurses notes • Vital signs • Intravenous fluids

24. Pathology Report • Description of tissue • Macroscopic • Microscopic • Full written report

25. Consultation Reports • Documents the clinical opinion of physician other than attending physician • Requested by attending physician

26. 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: • Uncomplicated stay of less than 48 hours • Uncomplicated delivery of normal newborn

27. Patient Instructions and Transfer Records • Instructions given to patient at time of discharge • Transfer record is brief review of hospitalization

28. 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

29. Obstetrics and Newborn Documentation • Obstetric record • Prenatal record from physician office • Admission evaluation • Record of labor • Delivery record • Newborn record • Birth history • Newborn identification • Physical exam

30. Administrative Data • Includes demographic and financial information • Demographics is study of the statistical characteristics of human population • Name • Address • Phone number • Financial • Insurance company • Policy numbers

31. Other Administrative Information • May also find: • Property lists • Birth certificate • Death certificate

32. Consents, Authorizations, and Acknowledgements • Consent to treat • Notice of privacy practices • Authorizations related to the release and disclosure of confidential health information

33. Advanced Directives • Written document that names legal representative for healthcare purposes • Living wills • Durable power of attorney • Patient Self-Determination act • Policies where patients can accept for refuse medical treatment • Patients notified of rights in making treatment decisions • Document presents of advance directive

34. Acknowledgement of Patient’s rights • Medicare Conditions of Participation give patient right to: • Know who is providing treatment • Confidentiality • Receive information about treatment • Refuse treatment • Participate in care planning • Be safe from abusive treatment

35. Specialized Health Record Documentation • Emergency Care Documentation • Documents presenting problems • Diagnostic and therapeutic services

36. 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

37. Emergency Care Documentation • Diagnostic impression • Medications administered • Conclusions • Final disposition • Condition on discharge/transfer • Patient instructions • Documentation of patient leaving against medical advise (where appropriate)

38. Ambulatory Care Documentation • Includes physician offices, clinics, hospital outpatient, neighborhood health, public health, industrial health, and urgent care settings

39. Ambulatory Care Documentation • Registration forms • Problem lists • Medication lists • History and physicals • Progress notes • Results of consultations • Diagnostic test results

40. Ambulatory Care Documentation • Flow sheets (pediatric growth charts, immunization records, etc.) • Copies of records from previous hospitalizations • Correspondence • Consents to disclose information • Advanced directives

41. Problem List • List of significant current and past illnesses and conditions and procedures

42. Obstetric/Gynecologic Care Documentation • Medical history • Reason for visit • Health status • Dietary/nutritional assessment • Physical fitness and exercise status • Tobacco, alcohol, and drug usage • History of abuse or neglect • Sexual practices including high-risk behaviors and method of contraception

43. Obstetric/Gynecologic Care Documentation • Physical examination • Lab tests

44. Pediatric Care Documentation • Past medical history • Birth history • Nutritional history • Personal, social, and family history • Growth and development record • Review of systems

45. Ambulatory Surgical Care Documentation • Free standing ambulatory surgery centers • Records are similar to hospital-based surgery department

46. 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

47. Long Term Documentation • Skilled nursing facilities • Subacute care facilities • Nursing facilities • Intermediate care facilities • ICFs for the mentally retarded • Assisted-living facilities

48. 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

49. 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

50. 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