1. Introduction to the Health Record

2. Getting to Know the Health Record
Users & Uses
Data-Information-Knowledge-Wisdom

3. What is a Health Record? The Legal Health Record
It is the means that healthcare providers use to collect and store the clinical documentation they created for individual patients while providing healthcare services during any aspect of healthcare delivery in any type of healthcare setting/organization.
The legal health record must meet the standards that have been defined by CMS Federal Regulations, and accrediting agencies such as the Joint Commission, as well as the policies of the health care provider (ex: CMS conditions of participation – state that an order must contain, pt name/dob/dx-symptom/procedure or test to be performed/physicians signature/date/time.),
It is the record that will be released upon request
Created for each individual patient/patient centric

4. Other names for the Health Record?
Medical Record
Healthcare Record
Chart
Patient Record
Clinical Record
Client Record
File
Synonyms:
medical record
health care record
Chart
patient record
clinical record
client record
file

5. Who owns the Health Record?
Patient & Physician
Hospital owns the original documentation – a physician or patient can’t have or take the original documentation out of the facility.
The patient owns the information within the chart, Wisconsin Law and HIPAA allows us to charge for copies - Typically there is no charge for continuing care

6. Importance of the Health Record
Care
Improving Patient Care
Patient’s Personal Use
Research
Care
Physicians, Nurses, Allied Health Professionals (Therapists – physical, occupational, speech), Dietician, Phlebotomist, Diagnostic Technicians (radiology/echo/stress)
Improving Patient Care
Quality Management Staff– retrospective review (chart is reviewed after the patient has been discharged)– Name some CMS quality measures; concurrent reviews (patient is still in house) – name some CMS quality measures –
Reimbursement (Support and Collection)
Starts with the HUC’s entering in charges. Charges are placed on the patients account throughout the patients stay. The HUC will charge the patients account for all medications given, IV’s administered, tests received (lab/radiology etc..), therapy… that chart needs to support each charge
Coders review the record and determine all diagnoses codes and procedure codes based on the physician documentation
A bill is then generated in the Business Office in which the Business Office Staff review the bill and send to insurance company.
The Insurance company pays the bill – they may request to review the record if they want to challenge the charges and deny the payment in which case the health care record will be sent for review.
Licensure, Accreditation, and Certification
State, TJC, CARF – review records to make sure that all required documentation is being done and being done accurately and consistently – example – all telephone orders need to be signed with 48 hours, all documentation must be authenticated/dated and timed, all patients must be assessed for pain, all patients that are admitted to a hospital and/or have invasive surgery require a history and physical and it must be no greater than 7 days old and must be updated on the day of surgery/admission.
HIM Staff – review each record post discharge for missing elements that are required by the physicians – will track all deficiencies in the record for each physician – will notify physician to complete.
Litigation
Malpractice – physician and facility will use the health record to defend themselves…In all states the health record is considered a legal document. It can be used as evidence is a court of law. “if it isn’t documented, it didn't happen.” - Give example of physician required to obtain consent for a procedure – needs to have the pt sign and physician needs to sign and it needs to state that all risks and benefits have been explained. Ex of physician being sued because of the outcome of a procedure in which the patient was unaware of the complications/risks that happened and there was NO signed consent for the procedure to prove that the physician discussed
MVA’s – to show injury and cost and pain and suffering
Workers Comp – did the injury really happen at work…
Research
Data is also collected by the HIM Clinical Data Registrar’s – Birth, Cancer, Trauma
Typically must get approval by the IRB – study looking at a particular disease/treatment, procedure, etc…,
Patient’s Personal Use
Patient can choose to use their health care record for any reason – HIM staff need to process the record and provide a copy to the patient

7. Importance of the Health Record
Reimbursement
Care
Physicians, Nurses, Allied Health Professionals (Therapists – physical, occupational, speech), Dietician, Phlebotomist, Diagnostic Technicians (radiology/echo/stress)
Improving Patient Care
Quality Management Staff– retrospective review (chart is reviewed after the patient has been discharged)– Name some CMS quality measures; concurrent reviews (patient is still in house) – name some CMS quality measures –
Reimbursement (Support and Collection)
Starts with the HUC’s entering in charges. Charges are placed on the patients account throughout the patients stay. The HUC will charge the patients account for all medications given, IV’s administered, tests received (lab/radiology etc..), therapy… that chart needs to support each charge
Coders review the record and determine all diagnoses codes and procedure codes based on the physician documentation
A bill is then generated in the Business Office in which the Business Office Staff review the bill and send to insurance company.
The Insurance company pays the bill – they may request to review the record if they want to challenge the charges and deny the payment in which case the health care record will be sent for review.
Licensure, Accreditation, and Certification
State, TJC, CARF – review records to make sure that all required documentation is being done and being done accurately and consistently – example – all telephone orders need to be signed with 48 hours, all documentation must be authenticated/dated and timed, all patients must be assessed for pain, all patients that are admitted to a hospital and/or have invasive surgery require a history and physical and it must be no greater than 7 days old and must be updated on the day of surgery/admission.
HIM Staff – review each record post discharge for missing elements that are required by the physicians – will track all deficiencies in the record for each physician – will notify physician to complete.
Litigation
Malpractice – physician and facility will use the health record to defend themselves…In all states the health record is considered a legal document. It can be used as evidence is a court of law. “if it isn’t documented, it didn't happen.” - Give example of physician required to obtain consent for a procedure – needs to have the pt sign and physician needs to sign and it needs to state that all risks and benefits have been explained. Ex of physician being sued because of the outcome of a procedure in which the patient was unaware of the complications/risks that happened and there was NO signed consent for the procedure to prove that the physician discussed
MVA’s – to show injury and cost and pain and suffering
Workers Comp – did the injury really happen at work…
Research
Data is also collected by the HIM Clinical Data Registrar’s – Birth, Cancer, Trauma
Typically must get approval by the IRB – study looking at a particular disease/treatment, procedure, etc…,
Patient’s Personal Use
Patient can choose to use their health care record for any reason – HIM staff need to process the record and provide a copy to the patient
“I’ll have someone come in and prep you for the bill.”

8. Importance of the Health Record
Licensure, Accreditation, & Certification
Litigation

9. Health Data
Health Data is simply data that is related to health – temperature, blood pressure,
Birth Registries collect data such as Mom’s age, marital status, habits (smoking/drugs), age, ethnicity, delivery type (c-section/vaginal), Apgars,
outcome of baby (normal/abnormalities) – provides us with useful information on groups that are high risk, etc
Cancer Registries collect data on all types of cancer. Positive Pathology reports trigger the cancer registry to pull the patients chart and abstract data that can be organized into useful information. Patient Demographics, types of cancer, stage of cancer, types of treatments, provides us good information about successful treatments, outcomes/survival rate for all cancers.

10. Collecting Health Care Data
Data are collected in logical segments
Characters
Fields
Records
Files
Characters – smallest unit of data – the letter “M” or the number “3” – it is the building blocks of data – when you put characters together you complete words and numbers . Characters must be placed in the correct order so that the data is correct. Ex: If you type in the wrong character it will change the entire number which could mean an error in documenting into the wrong electronic record.
Fields – is the combination of characters - a series of related characters such as - “Medical Record Number”, “Name,” “DOB…etc..every blank in a form is a field –alpha/numeric/alphanumeric. So you can see why an error in entering a character can create incorrect information.. Wrong MRU… Wrong DOB… wrong SS#, Wrong MD when entering deficiencies,
Records – in the same way that characters combine to make a field, fields combine to make a record. Records are a compilation of fields that have some logical connection to one another.
Files – group of records creates a file (numerous records of different types of data for the same patient)

11. Collecting Health Care Data
Categories of Health Data
Demographic Data
Socioeconomic Data
Financial Data
Demographic Data includes basic factual details about the individual patient. Its purpose is to confirm the identity of the patient.
Demographic Data includes - Name, address, phone number, ss#, gender, dob, MRU, Case #, admission date, primary care physician, admitting physician, contact person/next of kin
Socioeconomic Data such as Martial status, Education, Race or ethnic origin,Personal habits (smoking, alcohol, drug use). How is this information useful?
Financial Data – detail about occupation, employer and insurance coverage – purpose – to complete claim forms submitted to 3rd party payors.
Ex: Name of Insurance Company and group policy number, Insured party’s member identification number, Guarantor – for minor or incompetent, Employer (name and address)
Clinical Data - All health data recorded about the patient – vitals, dx, tx, px, diagnostics, meds,

12. Collecting Health Care Data
Categories of Health Data
Clinical Data
Demographic Data includes basic factual details about the individual patient. Its purpose is to confirm the identity of the patient.
Demographic Data includes - Name, address, phone number, ss#, gender, dob, MRU, Case #, admission date, primary care physician, admitting physician, contact person/next of kin
Socioeconomic Data such as Martial status, Education, Race or ethnic origin,Personal habits (smoking, alcohol, drug use). How is this information useful?
Financial Data – detail about occupation, employer and insurance coverage – purpose – to complete claim forms submitted to 3rd party payors.
Ex: Name of Insurance Company and group policy number, Insured party’s member identification number, Guarantor – for minor or incompetent, Employer (name and address)
Clinical Data - All health data recorded about the patient – vitals, dx, tx, px, diagnostics, meds,

13. Plan Subjective Objective Assessment Patient’s description of symptoms
Physician’s observation
Assessment
Physician’s opinion
Plan
Treatment or further diagnostic evaluation
Why do we collect all of this Health Data? - Primary Reason for recording data is communication!
There has to be a thought process and a logic way in which we organize the data so that a decision can be made about a patient.
The Soap Note format is often used in the record for medical decision making.
Subjective = The patients own words
Objective = Physician Evaluation and use of diagnostic testing to figure out what is wrong
Assessment = Description of what the physician thinks is wrong based o the patient's statement and their objective review.
Plan = treatment plan – the course that the physicians going to take to treat the patient

14. Health Record Formats Universal Chart Order Integrated Source-Oriented
Problem-Oriented
Problem List
Paper Records can be sorted/organized in several different ways, they need to be organized in a logical manner
This typically depends on which type of facility the patient is being seen in and what type of service.
Need to be in a format in which documentation/information can easily be found
Each record in the Health Care Facility needs to be sorted/organized/formatted in the exact same order.
Why? Ease of use, each health care provider and support staff that use the record must know exactly where in a record something would be. If a physician was looking for his orders but each chart was organized differently, he/she would spend too much time flipping through the charts.
There are several different formats that can be used:
INTEGRATED RECORD – date oriented or sequential
Pages are in date order – can be in chronological or reverse chronological order page figure 3-12
Data collected in date order – chronological page figure 3-12
Real example:
OP – we file all OP encounters on the left hand side of the chart in reverse chronological order so the most current encounter is on top. If you think about it, the most current data is more relevant than the old data of the patient. If you filed in chronological order for the OP the most current would be on the bottom and you would have to flip a lot of pages to get to the last visit.
SOURCE-ORIENTED RECORD
Typically records are kept in date order and by source
The source can be the physician the nurse or other clinicians, source can also be source-system data – the source is from a particular system in which interpretations, summaries and notes are derived (EKG/Lab reports/radiology film).
Advanced Directives/Allergy&Medication/Physician Orders/Progress Notes/H&P & Consults/Graphics and Flow Sheets/Nursing Notes/Labs/Radiology/Diagnostics (stress test/EKG/EEG/telemetry)/Therapy/Procedures & Operative Reports/ IPOC/Consent Forms/Discharge Planning
The book states that this is complicated, however, I think . It is very simple.
Organized by the source of the information, it is useful when there are many items of data coming from different sources. Ex: IP stay, numerous labs, phys progress notes, orders, X-rays, nurses notes, medications…if all of these are just filed in date order it is very difficult to compare the data, if each type of document is filed together in date order it is very easy to compare data. If all labs are together you can see what happened day to day.
Each document that corresponds to the tab is filed under that tab in date order. It can either be in reverse chronological order or in chronological order.
Labs, all labs are filed under lab
Physician Orders – all MD orders are filed under orders
Etc…
IP record – all source-orientated data are organized together and in date order, each visit in the chart is kept in “integrated” order or date order… in reverse chronological order (give examples)
Advantage/Disadvantage (ask class)
Advantage – easy to file, easy to compare data (all labs are together)
Disadvantage – hard to get the complete picture – go from nurses notes to physician notes to therapy notes
PROBLEM ORIENTED
When the chart is organized by the patients diagnosis or condition, ex: if the patient has diabetes and congestive heart failure, each one of these are treated separately and would be categorized under each disease.
Advantage – organized by disease so long-term management of chronic disease easier;
Disadvantage – hard to file and could duplicate data – for example – lab results might pertain to multiple disease processes that pt has.
PROBLEM LIST – integral part of the problem oriented record
List of patient’s diagnoses or complaints (seen in ambulatory clinics and ER’s mostly)

15. Electronic Health Record (EHR)
We are becoming more and more electronic
Data is collected in fields that are linked together so that it can be referenced easily and can be pulled together easily (displayed/printed/reports) – this is a MAJOR ADVANTAGE
Data is linked to the patient by reference numbers
MRU (higher level) – can look at all H&P’s that encompass all encounters
Case number (per visit) – can view by encounter
Advantages & Disadvantages
NOTE: the method of organizing a pt’s record is not pt specific.. All pt’s records are recorded the same way within a facility/office.