1. School of Health Sciences Week 4! AHIMA Practice Brief Fundamentals of Health Information HI 140 Instructor: Alisa Hayes, MSA, RHIA, CCRC

2. Class Reminders Contact Information AIM:AlisaCHayes Email: ahayes@kaplan.edu Office Hours By Appointment Chat conversations during class Please keep conversations focused on class. Type “pause” to comment and “?” to ask a question School of Health Science

3. AHIMA Practice Brief Health Records in Long Term Care (LTC) Objectives Compare and contrast the practice of health information management in a long term care (LTC) facility to an acute care facility Describe how completion of health records is typically handled in a LTC facility Describe the role of a health information consultant in LTC Explain the record retention requirements in LTC Describe the role of the Master Patient (Person) Index in LTC School of Health Science

4. AHIMA Practice Brief Health Records in Long Term Care (LTC) School of Health Science Long Term Care- includes nursing, social and rehabilitative services ongoing Length of Stay- average over 30 days Care provided- custodial, intermediate, rehabilitative, and skilled nursing care Health Information Departments in LTC Records include: nursing, rehabilitation, and physician progress notes Purpose of federal guidelines- a resource specific to long term care State regulations should be followed if different then listed in brief

5. AHIMA Practice Brief Health Records in Long Term Care (LTC) HIM Staff in LTC A Health Information Consultant A credentialed health information practitioner working in a facility A non-credentialed practitioner working in a facility A health unit coordinator School of Health Science

6. AHIMA Practice Brief Health Records in Long Term Care (LTC) Guidelines for LTC Health Information and Record Systems A record must be maintained for every resident in a long term care facility Long term care providers are at varying stages of automating their clinical documentation, there may be some portions of a record maintained electronically and some in paper format. Unit numbering best suited for LTC Each resident admitted to the long term care facility should be assigned a unique medical record number Continuum of Care in LTC- recommended that separate records are maintained for each of the different care settings. School of Health Science

7. AHIMA Practice Brief Health Records in Long Term Care (LTC) Content of the Medical Record in LTC- reflects the multi-disciplinary approach to assessment, care planning and care delivery Facility policy should specifically outline in the format of a chart order and the exact documents and records that will be considered part of the medical record. Identification in the Medical Record-core resident identification information appear on every page of record Thinning the LTC record- Goal and how it is done Schedule for thinning the medical records- It recommended that records are thinned quarterly and as needed Integrating other documents into the LTC record School of Health Science

8. AHIMA Practice Brief Health Records in Long Term Care (LTC) Resident identification- resident name, medical record number, date of birth, or social security number. Must be on every page of record. Facility identification- name of facility, mailing address and phone number. Must be on every page of record. Addressograph- machine used to imprint identification on each report. Dating and timing patient record entries- Month, date, and year-mmddyyyy Pre and Post dating is not allowed School of Health Science

9. AHIMA Practice Brief Health Records in Long Term Care (LTC) Forms Control Process Forms committee or patient record committee- established to oversee forms process and approve forms for use in record Role of committee Facilitate efficient use of patient record Streamline the forms approval process Ensure documentation is compliant Enhance quality of documentation School of Health Science

10. AHIMA Practice Brief Health Records in Long Term Care (LTC) Quantitative and Qualitative Analysis Admission, concurrent and discharge record monitoring Discharge Assembly and Analysis Record Completion after discharge- Records should be assembled, analyzed, and completed within 30 days of discharge Filing and Retrieval- Every long term care facility should have an established a system for filing and retrieving of their health records. HI disclosure-A LTC facility should send the most recent hospital history and physical report and discharge summary upon transfer to another facility if the information provides insight into the resident’s current health status or would be beneficial in the continued diagnosis and treatment. School of Health Science

11. AHIMA Practice Brief Health Records in Long Term Care (LTC) Documentation in the LTC record- should provide a picture of the resident and their response to treatment, changes in condition, and changes in treatment. Problems in LTC-duplication of information that is collected on different assessments and between the disciplines. Content in the LTC record Assessment Care Plan Summary School of Health Science

12. AHIMA Practice Brief Health Records in Long Term Care (LTC) Record retention requirements in LTC System is designed and implemented to ensure the safety, security, and accuracy of health records and resident- identifiable data Define a specific retention schedule for different types of records based on federal and state law and professional practice standards. Considering the required retention period, every facility should define in policy their specific retention period not to be less than the period defined by state or federal law School of Health Science

13. AHIMA Practice Brief Health Records in Long Term Care (LTC) The role of the Master Patient (Person) Index in LTC Valuable reference for basic demographic information and resident activity (i.e. admission and discharge dates) within one source Maintained separately from the resident’s medical record. It is used to identify that a resident had a stay in the facility, the dates of the stay and other important data in an easily retrievable format Manually or as part of a computerized system. MPI should be retained on a permanent basis Should be updated with changes throughout the residents’ stay Long term care facilities maintain the MPI alphabetically School of Health Science

14. Current Week 3/23/11-3/29/11 Unit 4 AHIMA Long Term Care (LTC) Brief LTC HIM questions Unit 4 Quiz School of Health Science

15. Next Week 3/30/11-4/5/11 Unit 5 Reading: AHIMA Practice Briefs (Automation of HI Functions) Learning activity: you will respond to the three- part assignment. The total length of this assignment should be 400-500 words. School of Health Science