LTC Health Information Practice & Documentation Guidelines Version 1.0 September 2001

Portions of these Guidelines are being updated and are available here

Table of Contents

Download entire draft in PDF format by clicking here.
Guidelines by section: Front matter  Chapters 1-3  Chap.4 pt.1  Chap. 4 pt.2  Chap. 4 pt.3  Chap. 5  Chaps. 6-7
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    1. Purpose and Use of These Guidelines
    2. Transition from Medical Records to Health Information (HIM)
    3. Definition of Long Term Care Facility
    4. Acknowledgements
    5. Copyright and Use of Report
    6. Reference to HIM Practice Standards
    1. Job Qualification, Responsibilities, and Functions of Health Information Staff in a LTC Facility
      1. Role of the Credentialed Consultant
      2. Role of the Credentialed Practitioner Working in a Long Term Care Facility
      3. Role of the Non-Credentialed Practitioner Working in a Long Term Care Facility
      4. Role of the Health Unit Coordinator
      5. Evolving Role of Health Information
    2. Health Information Department Staffing
    1. Frequency of Consultant Visits
    2. Performance Expectations for a Consultant
    3. Consultation Reports
      1. Timeliness of Consultation Reports
      2. Content of Consultation Reports
      3. Distribution of Consultation Reports
      4. Retention (Facility and Consultant)
    4. Evaluating Consulting Services
    1. Record Systems, Organization and Maintenance
      1. Maintaining a Unit Record
      2. Assigning a Medical Record Number
      3. Maintaining Records in a Continuum of Care
      4. Defining What is Part of the Medical Record
      5. Maintenance of the Chart
      6. Identification/Name and Medical Record Number on Pages
      7. Common Chart Forms and Thinning Guidelines
        1. Integrating Hospital Records into the Long Term Care Record
      1. Thinning the Medical Record
      2. Maintaining the Overflow Record of Thinned Documents
      3. Maintaining a "Soft Chart" or "Shadow Record" and Other Types of Records
      4. Forms Control Processes
    2. Audits and Quality Monitoring
      1. Qualitative vs. Quantitative Audits and Monitoring
      2. Assessing the Quality of Documentation
      3. Routine Audits/Monitoring (Criteria and Timeframes)
      4. Focus Audits and Monitoring Systems
      5. Integrating Audits/Monitoring into the QA/QI Program
      6. Retention of Audits, Checklists, and Monitoring Record
    3. Discharge Record Processing
      1. Discharge Record Assembly
      2. Discharge Record Analysis
      3. Timely Completion of a Discharge Record
      4. Incomplete and Delinquent Records
      5. Maintaining a Control Log for Discharge Records
      6. When to Close a Record on Temporary Absence
        1. Closing Records with a Change in Level of Care
        2. Closing Records with a Payer Change
    4. Filing and Retrieval
      1. Separate Location for Incomplete Records
      2. Typical Filing Systems
      3. After Hours Retrieval
    5. Storage Systems
      1. Storage System Options
      2. Security Issues: Locking Office and Storage Areas
      3. Alternative Storage Areas
    6. Retention
      1. Retention Guidelines
    7. Destruction
      1. Acceptable Methods of Destruction
      2. Abstracting Documents Prior to Discharge
      3. Destruction Logs and Witnesses
    8. Physical Security of Manual/Paper Records
      1. Maintaining a Record Checkout System
      2. What To Do If a Record Is Lost, Destroyed or Stolen
      3. Disaster Plans
    9. Confidentiality and Release of Information
      1. Identification of Confidential vs. Non-Confidential Information
      2. Resident Access to Their Records
      3. Confidentiality, Training and Agreements with Employees and Volunteers
      4. Resident Identification Boards at Nursing Stations
      5. Maintaining an Access/Disclosure Grid for Employees, Contractors and Outside Parties
      6. Handling a Request for Medical Records
        1. Review of Authorization for Release of Information
        2. Preparing a Record for Release
        3. Turn Around Time for Responding to a Request for Copies of Medical Records
        4. Copy Fees for Release of Information
        5. Documenting the Release of Information (Accounting of Disclosures)
      7. Redisclosure of Health information
        1. Redisclosure Upon Transfer to Another Healthcare Facility
      8. Handling Telephone Requests for Information
      9. Transmitting Patient Information Via Facsimile
      10. Responding to a Subpoena or Court Order
      11. Removing Original Records from the Facility
      12. Notice of Information Practices
      13. Designation of a Privacy Officer
    10. Coding and Reimbursement
      1. Training and Resources
      2. Frequency of ICD-9-CM Coding
      3. Coding and Billing Relationships
      4. Investigation of Claim Rejection/Denials Due to Coding
      5. Coding Issues Under Consolidated Billing
    11. Indexes and Registries
      1. Master Patient Index
        1. Maintaining an MPI
        2. Minimum Content
      2. Admission/Discharge Register
      3. Disease Index
    12. Minimum Statistical Reporting
      1. Total Admissions
      2. Total Discharges
      3. Average Daily Census
      4. Total Census Days
      5. Length of Stay
      6. Percentage of Occupancy
    1. Purpose and Definition of the Legal Medical Record
    2. Legal Documentation Standards
      1. Defining Who May Document in the Medical Record
      2. Linking Each Entry to the Patient
      3. Date and Time on Entries
        1. Timeliness of Entries
        2. Pre-dating and Back-dating
      4. Authentication of Entries and Methods of Authentication
        1. Signature
        2. Countersignatures
        3. Initials
        4. Fax Signatures
        5. Electronic/Digital Signatures
        6. Rubber Stamp Signatures
        7. Authenticating Documents with Multiple Sections or Completed by Multiple Individuals
      5. Signature Legends
      6. Permanency of Entries
        1. Printers
        2. Fax Copies
        3. Photo Copies
        4. Carbon Copy Paper (NCR)
        5. Use of Labels in the Medical Record
      7. Specificity
      8. Objectivity
      9. Completeness
      10. Use of Abbreviations
      11. Legibility
      12. Continuous Entries
      13. Completing All Fields
      14. Continuity of Entries – Avoiding Contradictions
      15. Condition Changes
      16. Document Informed Consent
      17. Admission/Discharge Notes
      18. Notification or Communications
      19. Delegation
      20. Incidents
      21. Make and Sign Own Entries
      22. Appropriateness of Entries – Keep Documentation Relevant to Patient Care
    3. Legal Guidelines for Handling Corrections, Errors, Omissions, and Other Documentation Problems
      1. Proper Error Correction Procedure
      2. Handling Omissions in Documentation
        1. Making a Late Entry
        2. Entering an Addendum
        3. Entering a Clarification
      3. Omissions on Medication, Treatment Records, Graphic and Other Flowsheets
      4. Documenting Care Provided by a Colleague
      5. Patient Amendments to their Record
      1. Federal Regulations Pertaining to Clinical Records
      2. Purpose of the Documentation
      3. Elimination of Duplication/Redundant Information when Evaluating/Implementing a Documentation System
    1. Documentation Content in a Long Term Care Record
      1. Admission Record
    2. Assessments
      1. Integrating Assessments with RAI Process
      2. Types of Assessments and Requirements
        1. Preadmission Assessment
        2. Admission Assessment
        3. Fall Assessment
        4. Skin Assessment
        5. Bowel and Bladder Assessment
        6. Physical Restraint Assessment
        7. Self-Administration of Medication
        8. Nutrition Assessment
        9. Activities/Recreation/Leisure Interest Assessment
        10. Social Service
        11. Mental and Psychosocial Functioning
        12. Restorative/Rehab Nursing Assessment
    3. Resident Assessment Instrument (RAI) – MDS and RAPS
    4. Care Plan
      1. Timeliness
      2. Care Conference
      3. Admission/Interim Care Plan
      4. Integrating Acute Problems Into the Care Plan
      5. Timeliness of Completion of Care Plan
      6. Authenticating Changes to Care Plan
    5. Narrative Charting and Summaries
      1. Admission/Readmission Note
      2. Content of Narrative Charting
      3. Monthly Summary Charting
      4. Integrated vs. Disciplinary Progress Notes
    6. Medicare Documentation
      1. Skilled Nursing/Therapy Charting
      2. Supporting Documentation for the MDS
      3. Therapy Treatment Time
      4. ADL Charting
      5. Mood and Behavior Documentation
      6. Hospital Documentation
      7. Medicare Certification/Recertification
    7. Rehabilitative Therapy Documentation – On-Hold
    8. Physician Documentation
      1. Physician Progress Notes
      2. Dictated Progress Notes
      3. NP/PA Documentation
      4. History and Physical
      5. Other Professional and Consultation Records/Notes
      6. Documenting Resident Diagnoses
      7. Supporting Documentation for Diagnoses
      8. Resolving Diagnoses
    9. Physician Orders
      1. Admission Orders
      2. Content of an Order
      3. Physician Order Recaps/Renewals
      4. Telephone Orders
      5. Fax Orders
      6. Standing Order Policies
      7. Authentication/Obtaining Signatures
      8. Transcription of Orders and Noting Orders
      9. Contacting the Physician to Obtain an Order
      10. Discontinuing an Order When a New Order is Obtained
      11. Updating/Changing Physician Order Recaps/Renewals After They Have Been Signed
      12. Processing Physician Orders After Hospitalization "Resume all Previous Orders"
      13. Verification of Hospital Orders with Attending Physician
      14. Accepting Orders From a NP/PA
      15. Accepting Orders from Specialists or Consultants
    10. Pharmacy Drug Review
    11. Antipsychotic Drug Therapy
      1. Dose Reduction Schedules and Documentation
    12. Medication and Treatment Records
      1. Starting new Medication/Treatment Records Upon Readmission/Hospital Return
    13. Flow Sheets/Flow Records
      1. Service Delivery Records
      2. Other Clinical Flow Records
    14. Labs and Special Reports
    15. Consents, Acknowledgements and Notices
      1. Informed Consent for Use of a Restraint
      2. Consent, Notice and Authorization to Use/Release Clinical Records
      3. Notice of Bedhold Policy and Readmission
      4. Notice of Legal Rights and Services
      5. Notice Before Transfer
      6. Notice Prior to Change of Room or Roommate
    16. Advance Directives
      1. DNR Order vs. Advance Directives
    17. Discharge Documentation
      1. Discharge Order
      2. Discharge Note
      3. Discharge Summary
      4. Transfer Form
      5. Physician’s Discharge Summary vs. Discharge Record