Documentation for Acute Care

Chapter 2

Functions of the Acute Care Health Record

Introduction

• 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) movement• 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

tool• 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 services

• 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 organizations

• 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 provided.

• Continuous quality improvement (CQI)

• FOCUS-PDA

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 payment:– The illnesses for which the patient received

care– The services and procedures the patient

received

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

• CPT

• ICD-10-CM

Documentation of Medical Necessity• Clinicians should indicate the location

where each service was performed• Physicians should enter final diagnostic

information in the same place in very record

• 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 treatments

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 organization

• Licensure – the process of granting an organization the right to provide healthcare services

• 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 body– 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 System

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 (MEDPAR)

– 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

representatives– Healthcare-related organizations