Documentation for Acute Care

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					Documentation for Acute Care

  Chapter 2
  Functions of the Acute Care
  Health Record
• Data – represents objective descriptions of
  processes, procedures, people, and other
  observable things and activities
• Information – the result of analysis of data
  for a specific purpose
Introduction – cont’d
• Initially all health record information was
  stored in paper format
• Handwritten progress notes, paper forms,
  photographs, graphic tracings, and
  typewritten reports
Electronic Health Record (EHR)
• Gained momentum since the
  implementation of HIPAA
• Implementation of ICD-10-CM and ICD-
  10-PCS will also add to the move to EHR
Principal Functions of the Acute
Care Record
• Repository for the clinical documentation
  relevant to the care and treatment of one
  specific patient
• Patient care delivery
• Patient care management
• Patient care support
• Billing and reimbursement
Functions of health record in
patient care delivery
• A data and information collection and storage
• A service documentation tool
• A communication tool for the patient’s caregivers
• A diagnostic tool
• A tool for patient assessment and care planning
• A health record is a risk assessment tool
• A discharge planning tool
EHR performs several additional
clinical functions
• Clinical decision support
• Error prevention tool
• Enhanced discharge planning tool
Functions of the health record in patient
care management and support
• The allocation of the healthcare
  organization’s resources
• The analysis of trends in the usage of
  patient services
• The forecasting of future demand for
• The communication of information of
  different clinical departments
Patient Care Management
• Case mix – a method of grouping patients
  according to a predefined set of characteristics.
• Case management – the ongoing review of
  clinical care conducted during the patient’s
  hospital stay
• Clinical practice guidelines – assist clinicians
  make knowledge – and experience-based
  decisions on medical treatment
Quality Management and
Performance Improvement
• JCAHO Core Measures – used to assess the
  quality management efforts of healthcare
• Quality Improvement Organizations (QIOs) –
  work under contract with CMS to conduct quality
  reviews for Medicare patients
• Credentialing – the process of reviewing and
  validating the qualifications of physicians who
  have applied for permission to treat patients in
  the facility.
Performance Improvement
• Systematic look at processes and
  outcomes to ensure the quality of services
• Continuous quality improvement (CQI)
Utilization Management
• Focuses on how healthcare organizations
  use their resources
• Utilization review – a formal process
  conducted to determine whether the
  medical care provided to a specific patient
  is necessary.
Risk Management
• Prevent situations that might put hospital
  patients, caregivers, or visitors in danger.
• Includes investigating reported incidents,
  reviewing liability claims, and working with
  hospital’s lawyers.
Legal Proceedings
• Four conditions must be met for a health record
  to be admissible as evidence:
  – The record must have been created as part of the
    provider’s regular business activities
  – The record must have been maintained as part of the
    provider’s regular business activities
  – The record must have been created at or near the
    time that the events occurred
  – The record must have been created by a person who
    had first-hand knowledge of the acts, events,
    conditions, and observations described in the record.
Billing and Reimbursement
• Health record documentation supports the
  billing and claims management processes
• Two main factors determine the amount of
  – The illnesses for which the patient received
  – The services and procedures the patient
Diagnostic and Procedural Coding
• Reimbursement claims communicate
  information about the patient’s illnesses
  through the use of diagnostic codes
• Information about services and procedures
  provided to the patient are communicated
  in the form of procedural codes.
Coding Systems
• ICD-9-CM
• ICD-10-CM
Documentation of Medical
• Clinicians should indicate the location
  where each service was performed
• Physicians should enter final diagnostic
  information in the same place in very
• Physicians should report the results of any
  preadmission tests or evaluations
• Physicians should document the patient’s
  specific diagnosis rather than symptoms
Documentation of Medical
Necessity – cont’d
• Clinicians should use the same medical
  terminology throughout the health record
• Clinicians should document any
  circumstances that resulted in treatment
  delays or slowed progress
• Clinicians should indicate the method of
  administration for medications and
Claims Processing
• Involves calculating charges, preparing
  and submitting reimbursement forms, and
  following up to make sure that appropriate
  payments were made.
• CMS – 1450
• CMS – 1500
• Submitted to third-party payers
  electronically - EDI
Ancillary Functions of the Acute
Care Record
• Accreditation – the process of granting
  formal approval to a healthcare
• Licensure – the process of granting an
  organization the right to provide healthcare
• Certification – the process of granting an
  organization the right to provide healthcare
  services to a specific group of individuals
Ancillary Functions of Acute Care
Records – cont’d
• Biomedical Research – the process of
  systematically investigating subjects
  related to the functioning of the human
  – Human subjects studies must meet federal
    and international guidelines
  – Informed consent
Ancillary Functions of Acute Care
Records – cont’d
• Education
• Morbidity and mortality reporting
  – National Vital Statistics System
     • Births
     • Deaths
  – Incidences of communicable diseases
• Management of the Healthcare Delivery
Ancillary Functions of Acute Care
Records – cont’d
• Secondary Data Sources
• Facility-Specific Indexes
  – Master patient index
  – Master physician index
  – Index of diseases
  – Index of operations
Ancillary Functions of Acute Care
Records – cont’d
• Registries
  – A collection of information related to a specific
    disease, condition, or procedure
  – Cancer Registry
  – Procedure registries
Ancillary Functions of Acute Care
Records – cont’d
• Healthcare Databases
  – Medicare Provider Analysis and Review File
  – National Practitioner Data Bank
  – Healthcare Integrity and Protection Data Bank
Users of the Acute Care Record
• “Those individuals who enter, verify,
  correct, analyze, or obtain information
  from the record, either directly or indirectly
  through an intermediary” – IOM
  – Caregivers
  – Patients, patients’ next of kin or legal
  – Healthcare-related organizations

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