HEALTH INFORMATION/ RECORD MANUAL

Health Information Record Systems Approval Approval/Health Information/Record Management Systems Responsibility for Records/Signature

Regulatory Documentation Requirements California (#0030) Iowa (#0031) Kansas (#0032) Missouri (#0033) Nevada (#0034) New Mexico (#0035) Texas (#0036)

Health Information/Record Service Organization Introduction – Defines the Clinical communication tool used among health care providers; A legal document that describes the health care services provided to the resident.

Introduction Each resident admitted to the center will have: A record (electronic and/or paper) initiated on admission; Completed in accordance with state and federal regulations; Accepted professional practices with formalized systems in place; Maintenance of records; Records are readily accessible; Accurate both manual and electronic.

HIPAA Guidance in the Health Insurance Portability and Accountability Act (HIPAA) [45 C.F.R …], Department of Health and Human Services Part 160 and 164 Breach Notification for Unsecured Protected Health Information and any subsequent HIPAA rules and applicable other State and Federal laws/regulations. Refer to Skilled HC.

Organization Record Responsibility(#1015) – See sample on following slide Interview Tool Questions (#1016) – See sample on following slide Interview Tool Answers (#1017) Job Description Health Information Director (#1020) Job Description Regional HI Management Coordinator (#1025 – See Skilled HC)

Record Responsibility (Sample)

Interview Tool Questions (Sample)

Organization -2 Staff Development/Orientation/Training (#1035) – See sample on following slide Lesson Plan & Attendance Sheet (#1036) Health Information Director Orientation Training & Evaluation Checklist (#1037) Performance Measures / Staff Competencies / Training Guide (#1038) – See sample on following slide Health Information / Record Department System Skills Evaluation (#1039) Health Information/Record System Department Report to Administrator (#1040)

Staff Development /Orientation / Training (Sample)

Performance Measures /Staff Competencies (Sample)

Clinical Record Service/General Policies Legal Medical Record & Related Policies/Procedures (#2007) – Also Skilled HC Review Definition of Record Set (#2008) General Record Policies / Documentation Guidelines (#2010)

Clinical Record Service/General Policies -2 Resident Record Content (#2015) Admission Record/Face Sheet Advance Directive Acknowledgment / POLST Allergies Alternate Schedule of Physician Visits Ancillary Assessments Behavior Drugs/Psychotropic Bowel/Bladder Assessment Care Plan/Plan of Care Certification/Recertification Comprehensive Resident Assessment Instrument (MDS)

Clinical Record Service/General Policies -3 Resident Record Content (#2015)…cont. Consents/Rights Conservatorship Consultation Reports Diagnoses History/Physical Individual Health Care Instruction Interdisciplinary Discharge Summary Interfacility Transfer Report/Summary Laboratory/X-Ray/Diagnostic Reports Leave of Absence/Pass Record Length (Height)/Weight

Clinical Record Service/General Policies -4 Resident Record Content (#2015)…cont. Licensed Nursing Notes Medicare Medication and Treatment Administration Minimum Data Set (MDS) Monitors Mortician’s Receipt Notification to Physician Nurse Practitioner – see Physician Visits Nursing Assistant Notes Pharmacy Review Physician Assistants – see Physician Visits

Clinical Record Service/General Policies -5 Resident Record Content (#2015)…cont. Physician Extenders – see Physician Visits Physician Orders Physician Progress Notes Physician Visits Physician’s Discharge Summary Plan of Care – see Care Plan Possessions List Preferred Intensity of Care/No CPR/DNR Request Psychotropic – see Behavior Drugs Rehabilitative/Specialized Therapy Resident Data Set

Clinical Record Service/General Policies -6 Resident Record Content (#2015)…cont. Restorative Nursing Restraints-Physical Smoking Surrogate Decision Maker Thirty-Day Notice Tuberculosis Screening Turning Vital signs Weight

Willful Falsification / Willful Omission Willful Falsification/Willful Omission (#2025)

Readmission/Record Process Readmission (#3005) By State

Discharge Procedures Order of Filing/Shortened Discharge Chart (# #3507) - By State Discharge Chart Monitor (#3520) – See sample on following slide Incomplete Record Procedure (#3525)

Discharge Chart Monitor (Sample)

Health Information/Record Tasks Guide to Location of Items in Health Information / Record Department (#4005) Record Tasks (#4010) Monitoring Schedule (#4011) – See sample on following slide Number System/Filing (#4020) Unit Record (#4025)

Monitoring Schedule (Sample)

Establishing and Closing the Record, Filing, Clearance Establishing/Closing the Record (#4030) In-House Order of Filing (# #4037) – By State Clearance of Records / Thinning (#4040)

Establishing and Closing the Record, Filing, Clearance -2 Retrieval of Records – Chart Locator System (#4050) Lost Record / Reconstruction (#4055) Storage of Records / Destruction After Retention Period (#4060) Off-Site Storage of Records (#4065) Retention of Records – General (#4070)

Indices/Registries/Coding, Other Indices/Registries (#5005 – Refer to Skilled HC) Master Resident Index (#5010) Monthly Review of Physician Orders (#6005 – Refer to Skilled HC) Delinquent Visit/Follow-Up (#6010)

Disaster Planning, Ancillary Log, Committee Minutes Disaster Planning for Health Information (#6015 – Refer to Skilled HC) Laboratory/X-Ray Log (#6020 – Refer to Skilled HC) Guidelines for Committee Minutes (#6025 – Refer to Skilled HC)

Confidentiality/Security of Health Information – Refer to Skilled HC) Notice of Privacy Practices (#7001 ) Reporting of Unlawful/Unauthorized Access, Use and Disclosure of Protected Health Information (#7002) Use & Disclosure of PHI – Minimum Necessary (#7003) Resident Access to Records (#7007) Amendment/Addendum to Records (#7009) Subpoena (#7011) Ombudsman/Review of Records (#7013) Accounting/Tracking of Disclosures (#7015) Facsimile (Fax) Machines (#7017) Confidentiality/Security of Information – Manual/Automated (#7019) Training in Privacy Regulations (#7021)

Monitors/Completion Instructions Monitor Schedule – See #4011 Monitors – with Policy/Procedure and Instructions (alphabetized) – Section 7050 Admission Monitor Change of Condition Monitor - See sample on following slide CNA / ADL Flow Sheet Monitor General Update / Clinical Record Monitor (Pacific Region) General Update Log (Central/Midwest Regions)

Monitors/Completion Instructions -2 Monitors – with Policy/Procedure and Instructions (alphabetized) – Section 7050 Medication / Treatment Monitor Pressure Sore/Ulcer/Skin Conditions Monitor

COC Monitor (Sample)

Additional Monitors – with Brief Instructions- Section #7051 Advance Directive/IHCI/Preferred Intensity of Care (PIC) /Physician Orders for Life Sustaining Treatment (POLST) Monitor Behavior Drug Monitor Bowel/Bladder Training Monitor Care Plan Monitor (Future) Diabetic Monitor Dialysis Monitor Hospice Monitor

Additional Monitors – with Brief Instructions- Section # Intake/Output/Catheter Monitor (Future) Licensed Progress Note Monitor Respite Care Monitor (Future) Restrictive Device/Restraint Monitor Weight Monitor/Weekly Weight Monitor/Weight Log - See Skilled HC

Additional Monitors – with Brief Instructions Medication/Treatment Self Monitor (#7052 – Future) Monitors/Completion Instructions – EHR System (#7053 – Future) Monitors/Completion Instructions – Manual (#7054 – Future)

Resident Assessment/Prospective Payment System/Medicare Electronic Signatures (#8020 – Refer to Skilled HC) Medicare Log (#8025 – Refer to Skilled HC) Medicare Certification/Re-Certification (#8030 – Refer to Skilled HC)

Miscellaneous Abbreviations/Symbols (#9005 – Future) Request for Hospital Information – Sample Letter to Acute Hospital for Records (#9010)

Hyperlinks to State Regulations – Appendix A California Iowa Kansas Missouri Nevada New Mexico Texas

HIM Record Manual Questions or Corrections – Appendix B Contact and for any updates, changes, Or fax to AHIS’ office at

Questions? Rhonda L. Anderson, RHIA President Anderson Health Information Systems, Inc. 940 W. 17 th Street, Suite B Santa Ana, CA Tel. 714/ Mobile 714/