HITT1301 - Chapter 4

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Health Information
Management Technology:
An Applied Approach,
Sixth Edition

Chapter 4: Health Record Content and
Documentation

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Documentation

•Recording of pertinent healthcare
findings, interventions, and responses
to treatment as a form of communication

• "Paint the picture, tell the story"

• As a coder, you will use the documentation in the record to code the encounter and give a full, clear description via codes.

What happens to coding if documentation is lacking?

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Impact of Poor Documentation

•Poor outcomes

If the MD doesn't document that the patient is allergic to penicillin, and the next provider that sees them gives them penicillin...
•Issues with patient care

If the MD doesn't document the reason the patient is being referred to a specialist..
•Issues with the accuracy of dx and procedure codes

If the MD doesn't document that the patient has a LEFT sided hernia...
•Errors on healthcare claim

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•Describes the principles, codes, beliefs,
guidelines, and regulations that guide healthcare
documentation.
•Dictates how healthcare providers should
document the treatment and services within the
health record.

Documentation Standards

​This helps keep medical records uniform and understandable across the board

Multiple Select

What is the purpose of documentation standards? Select all that apply

• To require physicians to document properly or pay a fine

• To make medical records uniform

• To provide guidelines for how documentation should be in the medical record

• To make sure the doctor is paying attention

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Standard

•Set of principles, codes, beliefs, guidelines,
and regulations that have been vetted and
agreed upon by an individual or a group of
individuals.

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Documentation Standard

•Standard that controls health record
documentation

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•EHRs and paper-based health records typically have
the same basic documentation standards
•Templates

Documentation Standards and EHRs

​Templates allow basic information to be pre-filled to ensure important information isnt missed.

Your New Patient form is a type of template. It makes sure the receptionist doesnt miss any important information

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Standards

•Documentation standards have grown in
complexity and detail over time
•Focus on

• Patient care quality
• Appropriate reimbursement
• Prevention of fraud and abuse

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Standards

•Documentation standards vary upon the
type of health record
•Multiple sources of documentation
standards:

•Insurance company or payers
•Government regulatory agencies
•Licensing boards
•Accrediting bodies
•Facility policies and procedures
•Medical staff bylaws

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Goals of Documentation Standards

•Ensure complete health record and accurately
reflects the treatment provided to the patient
•Drive appropriate reimbursement through accurate
code capture

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Medical Staff Bylaws

•Standards governing the practice of medical staff
members
•Voted on by the organized medical staff and the
medical staff executive committee
•Approved by the healthcare organization’s board of
directors
•Used to enforce quality of care

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•Required by

• Licensure organizations
• Accreditation organization
• Federal and state regulatory agencies

•Each organization mandates content
•Medical staff bylaws will vary slightly from one
organization to another

Medical Staff Bylaws

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Medical Staff

•Physicians and nonphysician providers who have
privileges to practice medicine at a particular
healthcare organization
•May or may not be employed by the healthcare
organization
•Medical staff are subject to the medical staff
bylaws

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Medical Staff Privileges

•Specific services and procedures that the medical
staff member is deemed qualified to perform, at a
particular healthcare provider organization

​PRIVILEGES

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Accreditation

•A voluntary process
•Periodical evaluation against preestablished written
criteria
•Healthcare organizations measure their own
compliance with standards
•Enhances the reputation of the organization in the
eyes of the patient
•Differs by the type of program or service

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Accreditation

•Healthcare organizations that are accredited by
an approved accreditation organization are
exempt from routine state survey agencies

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Accreditation Organization

•Must go through its own CMS review to obtain
deemed status

• Evaluates healthcare organizations for compliance with

CoPs and CFCs

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Joint Commission

•Accredits wide variety of healthcare
organizations
•Continuously updates survey processes
•Surveys clinical and operational components
•Provides education to healthcare organizations
related to compliance

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Joint Commission

•Provides accreditation for:

• Ambulatory healthcare
• Behavioral health
• Critical access hospital
• Homecare
• Hospital
• Laboratory
• Nursing care centers
• Physician offices
• Office-based surgery centers

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Other Accreditation Organizations

•Healthcare Facilities Accreditation Program
•Commission on Accreditation of Rehabilitation
Facilities
•Accreditation Association for Ambulatory
Healthcare

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State Statutes

•Legislation written and approved by
a state legislature and then signed
into law by the state’s governor
•Addresses the documentation
requirements for specific types of
health records

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Legal Health Record

•Documents and data elements that a healthcare
provider may include in response to legally
permissible requests for patient information

•Content varies from provider organization
to another

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Legal Health Record

•Policies and procedures should be established
to defining legal health record

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General Documentation Guidelines

•Apply to all categories of health records
•Every healthcare organization should have
policies
•Organized systematically to facilitate data
retrieval and compilation

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General Documentation Guidelines

•Only individuals authorized by the organization’s
policies should be allowed to enter
documentation in the health record.
•Organizational policy or medical staff rules and
regulations should specify who may receive and
transcribe verbal physician’s orders.

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General Documentation Guidelines

•Health record entries should be documented at
the time the services they describe are
rendered.
•Authors of entries should be clearly identified in
the record.
•Only abbreviations and symbols approved by
the organization or medical staff rules and
regulations should be used in the health
record.

Open Ended

When should healthcare documentation be entered into the record?

Multiple Choice

Only certain abbreviations and symbols are acceptable in the health record

• True

• False

• Potatoe

• Tomato

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General Documentation Guidelines

•All entries in the health record should be
permanent.
•Any corrections or information added to the record
by the patient should be inserted as an addendum

• No changes should be made in the original entries in the

record

• Information added to the health record by the patient

should be clearly identified as an addendum

​NOTHING can be deleted. Things can be striked through with a line to indicate "deletion" and correct information can be added as an addendum

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CMS Documentation Requirements

•Entries must be

• Legible
• Complete
• Dated and timed
• Author identified
• Authenticated in written or electronic form

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Authentication

•Identifying the source of health record entries

• Written signature
• Initials
• Electronic signature

•CMS requires controls to prevent any changes from
being made to the health record after the entries
have been authenticated

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Auto-Authentication

•When a physician or other care provider
authenticates an entry without reviewing

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Documentation by Setting

•Health record information consists of two types
regardless of setting

• Clinical
• Administrative

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Documentation by Setting

•Must have health record for each person
•Content varies by setting
•Contains clinical and administrative data

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Inpatient Health Record

•Patient stays overnight
•Medical or surgical
•Most complex health record

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Inpatient Health Record—Clinical

•Medical history

• Current condition
• Past medical history
• Personal history
• Family history
• Chief complaint

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Inpatient Health Record—Clinical

•Physical exam

• Physician assessment

•Diagnostic and therapeutic procedure order

• Physician order
• Standing order

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Inpatient Health Record—Clinical

•Clinical observation

• Progress note
• Integrated health record
• Summary statement (death)

•Care plan

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Inpatient Health Record—Clinical

•Autopsy report
•Vital signs
•Flow charts
•Diagnostic and therapeutic procedure reports

• Lab, pathology, and radiology and other

tests/treatments

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Inpatient Health Record—Clinical

•Anesthesia report
•Operative report
•Recover room report
•Pathology report
•Consultation report

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Inpatient Health Record—Clinical

•Discharge summary

• Overview of encounter
• Not required for hospitalization less than 48 hours,

uncomplicated delivery or newborn

•Patient instructions
•Transfer records

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Inpatient Health Record—Administrative

•Patient registration

• Demographics

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Special Health Records

•Some health records have unique requirements
because of the specialized services provided

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Obstetric and Newborn Health Record

•Obstetric

•Prenatal
•Labor and delivery

•Newborn

•APGAR

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Ambulatory Health Record - General

•Demographics
•Problem list

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Ambulatory Surgery Record

•Similar to inpatient surgical health record
•Follow-up post surgery

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Ancillary Departments

•Tests and procedures

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Physician Office Record

•Preventive care
•Minor illnesses and injuries

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Long-Term Care

•Ongoing assessments
•Care plan

• Resident Assessment instrument
• Minimum Data Set for Long-Term Care

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Rehabilitation

•Minimum Data Set, Version 3 (MDS 3.0) Resident
Assessment Instrument

• 5-Day Assessment (mandatory)
• Interim Payment Assessment (optional)
• Discharge Assessment (mandatory)

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Behavioral Health

•Includes similar content
•Family and caregiver input is documented

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Home Health

•Treatment plan
•Health assessment
•Problem list
•Treatment goals
•Interventions and outcomes

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Federal and State Initiatives on
Documentation

•Trends are to focus on

• Quality of care provided
• Value-based care

•Reimbursement provide incentives for quality of
care
•MACRA
•Core Measures

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Paper Health Record—Format

•Source-oriented health record
•Universal chart order
•Integrated health record
•Problem-orientated medical record

• Subjective, Objective, Assessment, Plan (SOAP)

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Electronic Health Record

•Point-of-care documentation
•Documentation captured electronically

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Web-Based Document Imaging

•Capture, digitize, integrate, store, and retrieve
paper-based health record documentation
•Organizes and assembles the paper-based health
record documentation, and controls the versioning,
access, and search capabilities of the
documentation

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Role of Healthcare Professionals in
Documentation

•Physicians

• Document appropriately so that quality care can be

rendered and that appropriate reimbursement can occur

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Role of Healthcare Professionals in
Documentation

•Nurses

• Documentation varies by licensing and regulatory

requirements, setting, and internal policy and
procedures

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Role of Healthcare Professionals in
Documentation

•Allied Health Professionals

• Many follow treatment plan developed by the patient’s

physician or a therapist or technologist

• Documents treatment and patient’s response

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HIM and Documentation

•Plays vital and different roles in the overall
governance of health record information
•Manages many aspects of the health record and its
content
•Used in coding, billing, and other HIM functions

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HIM Roles

•Clinical documentation integrity coordinator
•Analyst