AHIMA's Long-Term Care Health Information Practice and Documentation Guidelines

Download a PDF version of the Guidelines

Please note:
Portions of these guidelines are under revision to reflect regulatory and practice changes.

INTRODUCTION

• Purpose and Use of These Guidelines
• Transition from Medical Records to Health Information (HIM)
• Definition of Long Term Care Facility
• Acknowledgements
• Copyright and Use of Report
• Reference to HIM Practice Standards

ROLE OF HEALTH INFORMATION STAFF IN LONG-TERM CARE FACILITIES

• Job Qualifications, Responsibilities, and Functions of Health Information Staff in a Long-Term Care Facility
• Role of the Credentialed Consultant
• Role of the Credentialed Practitioner Working in a Long Term Care Facility
• Role of the Non-Credentialed Practitioner Working in a Long Term Care Facility
• Role of the Health Unit Coordinator (Unit Clerk/Secretary, Health Information Assistant)
• Evolving Role of Health Information
• Health Information Department Staffing

HEALTH INFORMATION CONSULTANT SERVICES

• Frequency of Consultant Visits
• Performance Expectations for a Consultant
• Consultation Reports
• Timeliness of Consultation Reports
• Content of Consultation Reports
• Distribution of the Consultation Reports
• Retention of Reports (Facility and Consultant)
• Evaluating Consulting Services

PRACTICE GUIDELINES FOR LTC HEALTH INFORMATION AND RECORD SYSTEMS

• Record Systems, Organization and Maintenance
• Maintaining a Unit Record
• Assigning a Medical Record Number
• Maintaining Records in a Continuum of Care
• Defining What is Part of the Medical Record
• Maintenance of the Medical Record
• Identification (Name and Number) on Pages of the Medical Record
• Common Forms and Thinning Guidelines
• Integrating Hospital Documents into the Long Term Care Record
• Thinning the Medical Record
• Maintaining the Overflow Record of Thinned Documents
• Maintaining a "Soft Chart" or "Shadow Record" and Other Types of Records
• Forms Control Processes
• Audits and Quality Monitoring
• Internal Qualitative vs. Quantitative Audits and Monitoring
• Assessing the Quality of Documentation
• Routine Audits/Monitoring (Criteria and Timeframes)
• Focus Audits and Monitoring Systems
• Integrating Audits/Monitoring into the QA/QI Program
• Retention of Audits, Checklists, and Monitoring Record
• Auditing the Electronic Health Record
• Discharge Record Processing
• Discharge Record Assembly
• Discharge Record Analysis
• Timely Completion of a Discharge Record
• Incomplete and Delinquent Records
• Maintaining a Control Log for Discharge Records
• When to Close a Record on Temporary Absence
• Closing Records with a Change in Level of Care
• Closing Records with a Payer Change
• Filing and Retrieval
• Separate Location for Incomplete Records
• Typical Filing Systems
• Retrieval
• Filing
• Storage Systems
• Storage System Options
• Security Issues: Locking of Office and Storage Areas
• Alternative Storage Areas
• Retention
• Retention Guidelines
• Destruction
• Acceptable Methods of Destruction - Paper-based Record
• Abstracting Paper Documents and Electronic Data Prior to Discharge
• Destruction Logs and Witnesses
• Physical Security of Manual/Paper Records
• Security Measures for Record Check Out—Manual
• Maintaining Security of Electronic Record Access
• What To Do If a Record Is Lost, Destroyed or Stolen
• Disaster Plans
• Confidentiality and Release of Information
• Identification of Confidential vs. Non-Confidential Information
• Resident Access to Their Records
• Confidentiality Training and Agreements with Employees and Volunteers
• Resident Identification Boards at Nursing Stations and other Facility Locations
• Maintaining an Access/Disclosure Grid for Employees, Contractors and Outside Parties
• Handling a Request for Health Information Contained in the Designated Record Set
• Consent for Use and Disclosure of Protected Health Information
• Redisclosure upon Transfer to Another Healthcare Facility
• Handling Telephone Requests for Information
• Transmitting Resident Information via Facsimile
• Responding to a Subpoena or Court Order
• Removing Original Records from the Facility
• Notice of Information Practices
• Designation of a Privacy Officer
• Coding and Reimbursement
• Training and Resources
• Frequency of ICD-9-CM Coding
• Coding and Billing Relationships
• Investigation of Claim Rejection/Denials Due to Coding
• Coding Issues Under Consolidated Billing
• Indexes and Registries
• Master Patient Index
• Maintaining an MPI
• Minimum Content
• Admission/Discharge Register
• Disease Index
• Minimum Statistical Reporting
• Total Admissions
• Total Discharges
• Average Daily Census
• Total Census Days
• Length of Stay
• Percentage of Occupancy
• Electronic Patient Records (on hold)

LEGAL DOCUMENTATION STANDARDS

• Purpose and Definition of the Legal Medical Record
• Legal Documentation Standards that Apply to Medical Records
• Defining Who May Document in the Medical Record
• Linking Each Entry to the Resident
• Date and Time on Entries
• Timeliness of Entries
• Pre-dating and Back-dating
• Authentication of Entries and Methods of Authentication
• Signature
• Countersignatures
• Initials
• Fax Signatures
• Electronic/Digital Signatures
• Rubber Stamp Signatures
• Authenticating Documents with Multiple Sections or Completed by Multiple Individuals
• Signature Legends
• Permanency of Entries
• Printers
• Fax Copies
• Photo Copies
• Carbon Copy Paper (NCR)
• Use of Labels in the Medical Record
• Specificity
• Objectivity
• Completeness
• Use of Abbreviations
• Legibility
• Continuous Entries
• Completing All Fields
• Continuity of Entries – Avoiding Contradictions
• Condition Changes
• Document Informed Consent
• Admission/Discharge Notes
• Notification or Communications
• Delegation
• Incidents
• Make and Sign Own Entries
• Appropriateness of Entries – Keep Documentation Relevant to Patient Care
• Legal Guidelines for Handling Corrections, Errors, Omissions, and Other Documentation Problems
• Proper Error Correction Procedure
• Handling Omissions in Documentation
• Making a Late Entry
• Entering an Addendum
• Entering a Clarification
• Omissions on Medication, Treatment Records, Graphic and Other Flowsheets
• Documenting Care Provided by a Colleague
• Resident Amendments to their Record

DOCUMENTATION IN THE LONG TERM CARE RECORD

• Federal Regulations Pertaining to Clinical Records
• Purpose of Clinical Records
• Elimination of Duplication/Redundant Information when Evaluating/Implementing a Documentation System:

• Documentation Content in a Long Term Care Record
• Admission Record
• Assessments
• Integrating Facility Assessments with Resident Assessment Instrument RAI) Process
• Types of Assessments and Requirements
• Preadmission Assessment
• Admission Assessment
• Fall Assessment
• Skin Assessment
• Skin at Risk Assessment
• Actual Skin Problems/Pressure Ulcer
• Bowel and Bladder Assessment
• Physical Restraint Assessment
• Self-Administration of Medication
• Nutrition Assessment
• Activities/Recreation/Leisure Interest Assessment
• Social Service
• Mental and Psychosocial Functioning
• Restorative/Rehab Nursing Assessment
• Rehabilitation Services
• Resident Assessment Instrument (RAI) – Minimum Data Set (MDS) and Care Area Assessment (CAA)
• Care Plan
• Timeliness
• Care Conference
• Admission Care Plan
• Integrating Acute Problems Into the Care Plan
• Timeliness of Completion of Care Plan
• Authenticating Changes to Care Plan
• Narrative Charting and Summaries
• Admission/Readmission Note
• Content of Narrative Charting
• Nursing and/or Interdisciplinary Summary Charting
• Integrated vs. Disciplinary Progress Notes
• Medicare Physician Certification
• Skilled Nursing/Therapy Charting
• Supporting Documentation for the MDS
• Therapy Treatment Time
• Activities of Daily Living (ADL) Charting
• Mood and Behavior Documentation
• Hospital Documentation
• Medicare Certification/Recertification
• Rehabilitative Therapy Documentation
• Physician Documentation
• Physician Progress Notes
• Dictated Progress Notes
• Nurse Practitioner (NP)/Physician Assistant (PA) Documentation
• History and Physical
• Other Professional and Consultation Records/Notes
• Documenting Resident Diagnoses
• Supporting Documentation for Diagnoses
• Resolving Diagnoses
• Final Progress Note/Discharge Note/Summary
• Physician Orders
• Admission Orders
• Content of an Order
• Physician Order Recaps/Renewals
• Telephone Orders
• Fax Orders
• Standing Order Policies
• Authentication/Obtaining Signatures
• Transcription of Orders and Noting Orders
• Contacting the Physician to Obtain an Order
• Discontinuing an Order When a New Order is Obtained
• Updating/Changing Physician Order Recaps/Renewals After They Have Been Signed
• Processing Physician Orders After Hospitalization "Resume Previous Orders"
• Verification of Hospital Orders with Attending Physician
• Accepting Orders From a Nurse Practitioner (NP)/Physician Assistant (PA) 
• Accepting Orders from Specialists or Consultants
• Pharmacy Drug Review
• Antispychotic Drug Therapy
• Dose Reduction Schedules and Documentation
• Medication and Treatment Records
• Starting new Medication/Treatment Records Upon Readmission/Hospital Return
• Flow Sheets/Flow Records
• Service Delivery Records
• Other Clinical Flow Records
• Labs and Special Reports
• Consents, Acknowledgements and Notices
• Informed Consent for Use of a Restraint
• Consent, Notice and Authorization to Use/Release Clinical Records
• Notice of Bedhold Policy and Readmission
• Notice of Legal Rights and Services
• Notice Before Transfer
• Notice Prior to Change of Room or Roommate
• Advance Directives
• DNR Order vs. Advance Directives
• Discharge Documentation
• Discharge Order
• Discharge Note
• Discharge Summary
• Transfer Form
• Physician’s Discharge Summary vs. Discharge Record
• Post Discharge Plan of Care
• Agreements
• Advanced Beneficiary Notice
• Generic Notice
• Detailed Notice of Termination of Medicare Benefits
• Documentation Systems/Formats

CHECKLIST OF HIM POLICY AND PROCEDURES

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