Documentation for Acute Care

1. Documentation for Acute Care Chapter 2 Functions of the Acute Care Health Record

2. 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

3. Introduction – cont’d • Initially all health record information was stored in paper format • Handwritten progress notes, paper forms, photographs, graphic tracings, and typewritten reports

4. 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

5. 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

6. 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

7. EHR performs several additional clinical functions • Clinical decision support • Error prevention tool • Enhanced discharge planning tool

8. 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

9. 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

10. 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.

11. Performance Improvement • Systematic look at processes and outcomes to ensure the quality of services provided. • Continuous quality improvement (CQI) • FOCUS-PDA

12. 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.

13. 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.

14. 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.

15. 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

16. 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.

17. Coding Systems • ICD-9-CM • CPT • ICD-10-CM

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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