School of Health Sciences Week 4! AHIMA Practice Brief

School of Health Sciences

Week 4!Week 4!

AHIMA Practice BriefAHIMA Practice Brief

Fundamentals of Health Information HI 140

Instructor: Alisa Hayes, MSA, RHIA, CCRC

Class Reminders

Contact InformationAIM:AlisaCHayesEmail: [email protected]

Office HoursBy Appointment

Chat conversations during classPlease keep conversations focused on class. Type “pause” to comment and “?” to ask a question

School of Health Science

AHIMA Practice BriefHealth Records in Long Term Care (LTC)

Objectives

• Compare and contrast the practice of health information management in a long term care (LTC) facility to an acute care facility

• Describe how completion of health records is typically handled in a LTC facility

• Describe the role of a health information consultant in LTC

• Explain the record retention requirements in LTC

• Describe the role of the Master Patient (Person) Index in LTC




• Long Term Care- includes nursing, social and rehabilitative services ongoing

• Length of Stay- average over 30 days • Care provided- custodial, intermediate, rehabilitative, and skilled nursing care• Health Information Departments in LTC

•Records include: nursing, rehabilitation, and physician progress notes

•Purpose of federal guidelines- a resource specific to long term care•State regulations should be followed if different then listed in brief


HIM Staff in LTCA Health Information ConsultantA credentialed health information practitioner working in a

facilityA non-credentialed practitioner working in a facilityA health unit coordinator



Guidelines for LTC Health Information and Record Systems A record must be maintained for every resident in a long term

care facility Long term care providers are at varying stages of

automating their clinical documentation, there may be some portions of a record maintained electronically and some in paper format.

Unit numbering best suited for LTC Each resident admitted to the long term care facility should

be assigned a unique medical record number Continuum of Care in LTC- recommended that separate

records are maintained for each of the different care settings.



Content of the Medical Record in LTC- reflects the multi-disciplinary approach to assessment, care planning and care delivery

Facility policy should specifically outline in the format of a chart order and the exact documents and records that will be considered part of the medical record.

Identification in the Medical Record-core resident identification information appear on every page of record

Thinning the LTC record- Goal and how it is doneSchedule for thinning the medical records- It recommended that

records are thinned quarterly and as needed Integrating other documents into the LTC record



• Resident identification- resident name, medical recordnumber, date of birth, or social security number. Must be on every page of record.

•Facility identification- name of facility, mailing address and phone number. Must be on every page of record.

•Addressograph- machine used to imprint identification on each report. •Dating and timing patient record entries- Month, date, and

year-mmddyyyy•Pre and Post dating is not allowed



Forms Control ProcessForms committee or patient record committee- established to

oversee forms process and approve forms for use in recordRole of committee

Facilitate efficient use of patient record Streamline the forms approval process Ensure documentation is compliant Enhance quality of documentation



• Quantitative and Qualitative Analysis• Admission, concurrent and discharge record monitoring • Discharge Assembly and Analysis• Record Completion after discharge- Records should be assembled,

analyzed, and completed within 30 days of discharge• Filing and Retrieval- Every long term care facility should have an

established a system for filing and retrieving of their health records.• HI disclosure-A LTC facility should send the most recent hospital

history and physical report and discharge summary upon transfer to another facility if the information provides insight into the resident’s current health status or would be beneficial in the continued diagnosis and treatment.



• Documentation in the LTC record- should provide a picture of the resident and their response to treatment, changes in condition, and changes in treatment.

• Problems in LTC-duplication of information that is collected on different assessments and between the disciplines.

• Content in the LTC record• Assessment• Care Plan• Summary



Record retention requirements in LTC System is designed and implemented to ensure the safety,

security, and accuracy of health records and resident-identifiable data

Define a specific retention schedule for different types of records based on federal and state law and professional practice standards.

Considering the required retention period, every facility should define in policy their specific retention period not to be less than the period defined by state or federal law



The role of the Master Patient (Person) Index in LTC Valuable reference for basic demographic information and

resident activity (i.e. admission and discharge dates) within one source

Maintained separately from the resident’s medical record. It is used to identify that a resident had a stay in the facility, the dates of the stay and other important data in an easily retrievable format

Manually or as part of a computerized system.MPI should be retained on a permanent basisShould be updated with changes throughout the residents’ stayLong term care facilities maintain the MPI alphabetically


Current Week• 3/23/11-3/29/11

Unit 4AHIMA Long Term Care (LTC) BriefLTC HIM questionsUnit 4 Quiz


Next Week3/30/11-4/5/11

Unit 5Reading: AHIMA Practice Briefs

(Automation of HI Functions)Learning activity: you will respond to

the three-part assignment. The total length of this assignment should be 400-500 words.



Documents

School of Health Sciences Week 4! AHIMA Practice Brief