Chapter 4 HIT114(PP and Book questions)

Recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregivers.
Allows for the telling and re-telling of events.
Documentation Standards
Describes those principles, codes, beliefs, guidelines, and regulations that guide healthcare documentation.
Dictates how healthcare providers should document the treatment and services within the health record.
Are evaluated conformance with a generally accepted rule.
EHR and paper-based
health records that typically have the same basic documentation standards.
Documentation _______ have grown in complexity and detail over time.
Focus on patient care quality, appropriate reimbursement, and the prevention of fraud and abuse.
Sources of Documentation Standards
Insurance company or payers
Government regulatory agencies
Licensing boards
Accrediting bodies
Facility policies and procedures
Medical staff bylaws
Goals of Documentation Standards
Ensure complete health record and accurately reflects the treatment provided to the patient.
Provide overall inherent level of acceptable quality.
Drive appropriate reimbursement through accurate code capture.
Medical Staff Bylaws
Standards governing the practice of medical staff members
Voted on by the organized medical staff and the medical staff executive committee
Approved by the facility’s board of directors
Used to enforce quality of care
Licensure organization
Accrediting and licensure organizations as well as federal and state regulatory agencies mandate the content of the bylaws
will vary slightly from one organization to another
Medical Staff
Group of physicians and non-physician providers who have privileges to practice medicine at a particular healthcare organization.
May or may not be employed by the healthcare organization.
__________ are subject to the medical staff bylaws.
Medical Staff Privileges
Specific services and procedures that the medical staff member is deemed qualified to perform, at a particular healthcare organization
Centers for Medicare and Medicaid Services (CMS)
Federal agency within the US Department of Health and Human Services(HHS).
Operational of the Medicare program in collaboration with state governments.
A voluntary process
Periodical evaluation of the quality of the entity’s work against pre-established written criteria
Healthcare organizations measure their own compliance with standards
Enhances the reputation of the organization in the eyes of the patient
Differs by the type of program or service
Accreditation Organization (AO)
Must go through its own CMS review to obtain deemed status
Joint Commission
Accredits wide variety of healthcare organizations.
Continuously updates survey processes.
Surveys clinical and operational components.
Provides education to healthcare organizations related to compliance.
deemed status
An official designation indicating that healthcare facility is in compliance with the Medicare Conditions of Participation.
Ambulatory healthcare
Behavioral health
Critical access hospital
Nursing care centers
Physician offices
Office-based surgery centers
Joint Commission Provides accreditation for:
Legislation written and approved by a state legislature and then signed into law by the state’s governor
Addresses the documentation requirements for specific types of health records
Legal Health Record
Supports revenue,supports testimony.
Documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information:
Content varies from provider organization to another:
May be hybrid record model:
Defining the ______________ is difficult with health information exchanges (HIEs)
General Documentation Guidelines
Apply to all categories of health records.
Every healthcare organization should have policies .
Organized systematically to facilitate data retrieval and compilation.
Only individuals authorized by the organization’s policies should be allowed to enter documentation in the health record.
Organizational policy or medical staff rules and regulations should specify who may receive and transcribe verbal physician’s orders.
Health record entries should be documented at the time the services they describe are rendered.
Authors of entries should be clearly identified in the record.
Only abbreviations and symbols approved by the organization or medical staff rules and regulations should be used in the health record.
All entries in the health record should be permanent.
Any corrections or information added to the record by the patient should be inserted as _________.
CMS documentation requirements
All patient medical record entries must be legible, complete, dated, times, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided consistent with hospital policies and procedures.
The process of identifying the source or health record entries by attaching a hand-written signature, the author’s initials, or an electronic signature.
CMS requires controls to prevent any changes from being made to the health record after the entries have been authenticated
When a physician or other care provider cannot authenticate an entry that he or she cannot review.
Administrative-patient’s demographics
Documentation by Setting;
Health record information consists of two types regardless of setting
Inpatient Health Record
It is generated when a patient is provided with room, board, and continuous general nursing care in an area of an acute-care facility.
Within the inpatient care services continuum, there are three major records types:
The ____________ health record is found in a variety of settings:
Inpatient care units
Long-term care facilities
Home health
Surgical centers
Ambulatory care units
Health record documentation will pertain to adult patients with various acute and active disease processes or injuries.
Basic Acute Care Content
Nine components:
Medical history-history of present illness,personal ,family history, travel history.
Physical exam-vital signs etc.
Diagnosis and therapeutic procedure orders-all drs order.
Clinical observations.
Diagnostic and therapeutic procedure reports-lab tests etc.
Procedure and surgical documentation-procedure note.
Consultation reports-drs opinion,requested by the provider.
Discharge summary-
Patient instructions and transfer records-instructions when you go home,transfer docs.
Patient account information
Basic Acute Care Content;

Insurance payer information.
Insurance policy holder information.
Patient’s relationship to the insurance policy holder.
Insurance policy number.

Special Health Records
Some health records have unique requirements because of the specialized services provided:
Medical history including history of abuse or neglect and sexual practices
Periodic routine laboratory testing
Additional laboratory testing for high-risk groups such as tuberculosis skin testing and testing for sexually transmitted diseases
EMTALA (Emergency Medical Treatment and Active Labor Act
Must stabilize patient in emergency
Prohibits healthcare providers from refusing to treat patients or delaying treatment due to inability to pay
overall goal of documentation standards
To ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient
conditions of participation
A hospital that participates in the medicare and medicaid program must follow:
assess the legal environment
When defining its legal health record, a healthcare provider organization must do which of the following?
medical history
Which of the following is the health record component that addresses the patient’s current complaints and symptoms and lists the patient’s past medical, personal and family history?
all categories of healthcare records
general documentation guidelines apply to:
administrative data
A patient’s gender,phone number,next of kin and insurance policy holder information would be considered what kind of data?
ambulatory record
Patient history questionnaires, problem lists, diagnostic tests results, and immunization records are commonly found in which type of record?
Behavioral health records
What type of health records may contain family and caregiver input?
Hospital operatives record
The ambulatory surgery record contains information most similar to which of the following?
(Commission on Accreditation of Rehabilitation Facilities)
Which group focuses solely on accreditation of rehabilitation programs and services?
Emergency care
Which type of health record contains information about the means by which the patient arrived at the healthcare setting and documentation of care provided to stabilized patient?
Long-term care
A patient’s registration forms, personal property list, (resident assessment instrument)RAI, care plan, and discharge or transfer documentation would be found most frequently in which type of health record?
General condition
Which of the following would not be found in a physical exam?
An attending physician requests the advice of a second physician who then reviews the health record and examines the patient. The second physician records his or her evaluation in what type of report?
Expressed consent
Written or spoken permission to proceed with care is classified as?
care plan
Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps.
Pathology report
Reports that provide information on tissue removed during a procedure.
A growth and development record may be found in what type of record?
Problem- oriented health record
The subjective, objective, assessment, plan (SOAP) method came from the:
Documentation-imaging technology
Which of the following electronic record technological capabilities would allow paper-based health records to be incorporated into a patient’s EHR?
Problem-oriented health record
The problem list is part of which of the following?
The paper health record has been scanned and is now available digitally. What is this known as?
Both subjective and objective
Nursing documentation within the health record will be:
(T/F) Health record entries should be documented at the time the services they described are rendered.
Only individuals authorized by the organization’s policies should be allowed to enter documentation in the health record.
Auto-authentication is the preferred method for authentication.
When an error is made, the erroneous information can be obliterated.
Many services such as surgery, infusions, and other diagnostic procedures that once required an overnight hospital stay for the patient, no longer requires that level of care.
CMS requires that healthcare providers inform their patients about general patient rights afforded to them.
Healthcare provider organizations normally have patients sign an acknowledgement acknowledging that the healthcare provider organization is not responsible for the loss and damage to the patient’s valuable.
Payers and the government are not concerned with how a physician documents in a health record.
Only physicians document in the health record.
HIM professionals document in the health record.
Management of health record information is a fundamental component of information governance.
The emergency department record itself is sometimes incorporated within the inpatient health record and at other times, is kept separately
Emergency Department Record
Arrival time
Means of arrival
Name of person bring patient to ED
Disposition of patient
Condition of patient on discharge
Ambulatory Record
Registration forms
Problem lists
Medication lists
Patient history questionnaires
History and physicals
Progress notes
Results of consultations
Diagnostic test results
Miscellaneous flow sheets (for example, pediatric growth charts and immunization records and specialty-specific flow sheets)
Copies of records of previous hospitalizations or treatment by other healthcare practitioners
Consents to disclose information
Advance directives
Ambulatory Surgery Record
Documentation of surgery
Records call to patient 24-48 hours after discharge
Ancillary Departments Record
Documentation of tests and treatments performed
Includes lab, radiology, pharmacy, and more
Long Term Care
Ongoing assessments
Resident Assessment Instrument
Minimum Data Set
Treatment plan
Typical health record documentation
Documentation varies based on inpatient or outpatient setting but includes:
Diagnosis of disability and functional diagnosis.
Rehabilitation problems, goals, and prognosis.
Typical health record documentation.
Health Information Media
Paper Health Record Format
Source-orientated health record
Universal chart order
Integrated health record
Problem-orientated medical record
Subjective, Objective, Assessment, Plan (SOAP)
Web-Based Document Imaging
Capture, digitize, integrate, store, and retrieve paper-based health record documentation;
Organizes and assembles the paper-based health record documentation, and controls the versioning, access, and search capabilities of the documentation.
Nurses Documentation varies by licensing and regulatory requirements, setting, and internal policy and procedures
Physician Office Record
Documentation of care in physician office includes:
Medical history
Family history
Social history
Vital signs
Chief complaint
Progress notes
Medication list
History of present illness
Review of systems-the dr’s physical exam
Assessment and diagnosis
Plan of treatment
Behavioral Health
Treatment plan;
Social worker’s assessment and documentation of the family or home environment and community services available;
Psychiatric evaluation;
Typical health record content.
Allied Health Professionals
Many follow treatment plan developed by the patient’s physician or a therapist or technologist ;
Documents treatment and patient’s response
Plays vital and different roles in the overall governance of health record information.
Manages many aspects of the health record and its content.
Roles are more information technology (IT) focused.
Universal chart order
The health record post patient discharge is kept in reverse chronological order called _______.

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