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									Documentation for Acute Care

  Chapter 4
  Organization and Management of
  Acute Care Health Records
Limitations of Paper-based health
• The need to adhere to a strict record
  format – “chart order”
• Can only be viewed by one user at a time
• Can be difficult to update
• Fragile
Formats for Paper-based Health
• Source-oriented health record
• Problem-oriented health record
• Integrated health record
Benefits of the Electronic Health
• Possible to access information quickly and easily
• Allow various levels of access and view
• Allow multiple users to access the same
  information simultaneously
• Perform complex or difficult tasks quickly
• Permit ready access to volumes of professional
  resource information
• Easily updates and maintained
Drawbacks of the EHR
• Expensive
• Require extensive training for health
  record users
Definition of the EHR
• An electronic patient record that resides in
  a system specifically designed to support
  users by providing accessibility to
  complete and accurate data, alerts,
  reminders, clinical decision support
  systems, links to medical knowledge, and
  other aide.
Database Models
• Centralized EHR – all of the organization’s
  patient health information and data are
  stored in a single EHR system.
• Clinical data repository
Health Information System
• Health Level Seven (HL7)
• American Society for Testing and
  Materials (ASTM)
• The Institute of Electronic and Electrial
  Engineers (IEEE)
• American College of Radiologists/National
  Electrical Manufacturers Association
Health Information System
Standards – cont’d
• International Standards Organization (ISO)
• Systematized Nomenclature of Medicine
• National Library of Medicine (NLM)
• Unified Medical Language System (UMLS)
HIS standards that must be
established and followed:
•   Health informatics standards
•   Vocabulary standards
•   Structure and content standards
•   Messaging standards
•   Privacy and security standards
Health Record Identification
• Unique identifier is assigned to each
  patient’s health record at the time of
• Health Record Numbering Systems
  – Serial Numbering System
  – Unit Numbering System
  – Serial-unit Numbering System
Health Record Filing System
• Alphabetic Filing System
• Numeric Filing System
  – Straight numeric filing system
  – Terminal-digit filing system
  – Alphanumeric filing system
Health Record Storage Systems
• Paper-based storage systems
  – Vertical or lateral filing cabinets
  – Open-shelf files
  – Compressible file systems
• Microfilm-based storage systems
• Digital image-based storage systems
Retrieval and Tracking Systems
• Requisition – written request for a specific
  health record from storage
• Outguide – a durable sheet of paper or
  vinyl that is inserted into a file to replace a
  health record that has been removed from
Standardization of Forms and
• Committee to oversee the development, review,
  and control of the facilities’ data capture tools.
• Committee membership:
   –   Health information management
   –   Medical staff
   –   Nursing staff
   –   Purchasing
   –   Information services
   –   Performance improvement
   –   Support or ancillary departments
Standardization of Abbreviations
• Policies and medical staff rules determine
  which symbols and abbreviations may be
  used by the clinicians in health record
• JCAHO Patient Safety Goals – one
  focused specifically on definition of
Authentication of Health Record
• Process of providing proof of authorship
• Paper-based records
  – Signature along with the author’s credentials and the
    date the entry was made
• Electronic records
  – Electronic signatures – a unique personal identifier
    that is entered by the author of the EHR
  – Digital signature – digitized version of a handwritten
Corrections in Clinical
Documentation – Paper-based
• Draw a single line in ink through the
  incorrect entry
• Print the word “error” at the top of the entry
• Authenticate the error notation by signing
  or initialing the notation and noting the
  date and time.
• Correct information is then added to the
  entry as a notation. Late entries should be
  noted as such.
Corrections to Clinical Documentation –
Electronic records
• Original entries must remain unchanged
• Corrections and late entries must be
  added as notations to the original entries.
• Corrections and late entries must be dated
  and authenticated by the author of the
Inclusion of other types of
documentation in acute care records
•   Use of copies from outside providers
•   Use of facsimiles and photocopies
•   Use of electronic communications
•   Patient-provider communications
•   Provider-provider communications
Health Record Analysis and
• Concurrent or ongoing review
• Quantitative analysis
• Qualitative analysis
Quantitative Analysis
• All of the necessary reports and data entry
  forms/screens have been completed
• All of the reports and data entry
  forms/screens include accurate patient
  identification information
• All of the necessary consents and
  authorizations have been signed by the
  patient or patient’s legal representative
Quantitative Analysis – cont’d
• All of the diagnostic tests ordered by the
  patient’s physician have been performed, and
  the results have been documented
• All of the medical consultations ordered by the
  patient’s physician have been performed, and
  the consultants’ reports are complete
• All of the entries and reports that require
  authentication have been signed and dated
  according to hospital diagnoses.
Quantitative Analysis – cont’d
• The history and physical examination
  report is complete and includes
  documentation of all admission diagnoses
• The discharge summary is complete
• The physician’s documentation includes all
  of the principal and additional diagnoses
  and principal and additional procedures.
Quantitative Analysis – cont’d
• For surgical patients:
   – All preoperative, intraoperative, and postoperative
     anesthesia reports are complete
   – All operative reports, pathology reports, and
     postoperative progress notes are complete
   – All recovery room reports and progress notes are
• For patients who died while under hospital care,
  preliminary and final autopsy reports are
  complete if an autopsy was ordered.
Deficiency Systems
• Paper-based – checklist to indicate
  missing orders, progress notes, reports,
  consents, and other documentation
• Computer-based – provide logs for
  reporting and tracking deficiencies
• Average record deficiency rate
  Monthly average number of delinquent records
  Monthly average number of discharges
Qualitative Analysis
• Check for obvious inconsistencies in
  documentation related to the diagnostic
  information recorded on admissions
  records, history and physical reports,
  operative reports and pathology reports,
  care plans, and discharge summaries
• Inconsistencies between the patient’s
  pharmacy profile and the medication
Qualitative Analysis – cont’d
• Ambiguities in documentation related to
  the use of unapproved symbols and
• Inconsistencies in nursing documentation
  related to the patient’s pain status
  compared to physician’s orders for
Qualitative analysis – cont’d
• Inadequacies in nursing documentation
  related to interdepartmental transfers that
  result in time gaps during which the
  patient’s location in not accounted for
Ongoing Review
• HIM professionals review records of
  current inpatients daily as well as closed
  records after the patients have been
  discharged or transferred.
• Ensure that inpatient health records are
  complete and accurate
Terminal Digit Filing
• Most common filing method of paper charts
• Traditional set-up 3 sets of 2 pair numbers
• In terminal digit, read right to left, file in numerical order.
• For example,
• the first pair of digits on the right is called primary (look at
  first when filing) (23)
• The second pair of digits (56) is called secondary number
• The third pair of digits is called the tertiary or final number

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