1. Documentation for Acute Care
Chapter 4
Organization and Management of Acute Care Health Records

2. Limitations of Paper-based health records
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

3. Formats for Paper-based Health Records
Source-oriented health record
Problem-oriented health record
Integrated health record

4. Benefits of the Electronic Health Record
Possible to access information quickly and easily
Allow various levels of access and view customization
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

5. Drawbacks of the EHR Expensive
Require extensive training for health record users

6. 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.

7. Database Models
Centralized EHR – all of the organization’s patient health information and data are stored in a single EHR system.
Clinical data repository

8. Health Information System Standards
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 (ACR/NEMA)

9. Health Information System Standards – cont’d
International Standards Organization (ISO)
Systematized Nomenclature of Medicine (SNOMED)
National Library of Medicine (NLM)
Unified Medical Language System (UMLS)

10. HIS standards that must be established and followed:
Health informatics standards
Vocabulary standards
Structure and content standards
Messaging standards
Privacy and security standards

11. Health Record Identification Systems
Unique identifier is assigned to each patient’s health record at the time of admission
Health Record Numbering Systems
Serial Numbering System
Unit Numbering System
Serial-unit Numbering System

12. Health Record Filing System
Alphabetic Filing System
Numeric Filing System
Straight numeric filing system
Terminal-digit filing system
Alphanumeric filing system

13. 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

14. 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 storage

15. Standardization of Forms and Views
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

16. Standardization of Abbreviations
Policies and medical staff rules determine which symbols and abbreviations may be used by the clinicians in health record documentation.
JCAHO Patient Safety Goals – one focused specifically on definition of abbreviations

17. Authentication of Health Record Entries
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 documentation
Digital signature – digitized version of a handwritten signature

18. 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.

19. 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 changes.

20. 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

21. Health Record Analysis and Management
Concurrent or ongoing review
Quantitative analysis
Qualitative analysis

22. 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

23. 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.

24. 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.

25. 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 complete
For patients who died while under hospital care, preliminary and final autopsy reports are complete if an autopsy was ordered.

26. 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

27. 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 record

28. Qualitative Analysis – cont’d
Ambiguities in documentation related to the use of unapproved symbols and abbreviations
Inconsistencies in nursing documentation related to the patient’s pain status compared to physician’s orders for analgesics

29. 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

30. 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

31. 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 (01)