Health Information Chapter 7
•The HIM department also monitors the quality of patient information, ensuring that the information is maintained and protected in accordance with federal, state, and local regulations and the guidelines issued by various accrediting bodies
•Although computers are used widely in healthcare organizations today, many organizations still have an enormous volume of information documented on paper.
•Monitoring of record completion
•Release of patient information
•Research and statistics
•Cancer and/or trauma registries
•Birth certificate completion
•The medical center is one of five hospitals belonging to the Midwest Healthcare systems.
•The medical center is a full-service teaching hospital with services ranging from medical, surgical, obstetrics, pediatrics, wound care, trauma care, and heart care, to outpatient clinics and services.
•CCMC has an average of 15,000 inpatient discharges each year and approximately 90,000 outpatient visits per year.
•Up until two years ago, Central Community Medical Center’s HIM department operated as a traditional paper-based health records department.
•The Healthcare system decided that all hospitals would use the same vendor to facilitate the interoperability and consistency of the EHR between facilities.
•Key players needed to be identified and included in the planning process
•The steering committee consisted of a project manager and approximately 20 individuals from the health information management team and information systems team.
•Workgroups were developed
•The HIM workgroup activities are discussed in this case study.
•Duplicate forms or forms with similar data were reviewed to determine if a common form could be used across departments.
•The forms included in the forms catalog, as well as, other sources of health record documentation were included in the matrix.
•For example, health record documentation generated and printed from the computer for inclusion in the health record (for example, printed laboratory results) was also identified and included in the documentation matrix.
•Source of the documentation (for example, internal, external)
•Documenter of the information (for example, nursing, physician, physical therapist, radiology, surgical department, laboratory, and so forth)
•Data capture methodology (for example, paper form, printed results, voice recognition, transcription, electronic forms, and so forth)
•Health record location (for example, physician section, nursing section, laboratory section, radiology section, and so forth)
•Name of computer systems used to provide electronic documentation
•The barcode on the forms was needed so forms could be automatically indexed and routed to the correct location within the EDMS. Indexing rules were applied to scanned images and electronically fed documentation
•The rules allowed the documentation to be auto-indexed to the correct location within the EDMS. Another task in form redesign was to standardize the location of the barcode on paper forms to be scanned.
•”Loose sheets” queues
•Birth certificate queues
•Release of information queues
•Physician decline queues
•Medical coding queues
•Records needing signature
•Records requiring text editing
•Medical coding queries
—Emergency department records
Cancer chart reviews
External review (temporary queues)
—Department of health reviews
•It was determined that fetal monitoring strips would be maintained on paper because of the inability to capture the monitoring information electronically and the time required to scan the continuous feed of monitoring strip paper after discharge
•Key clinical staff were trained in the “train-the-trainer” style
•Online training modules were available for staff unable to attend “live” training sessions
•Most of the physician training was accomplished on an individual basis
•The planned evolution of the paper health record to an electronic health record was a significant culture change for the health facility
•The employee assistance program was utilized to help manage the fears associated with the change
•Improvements to interoperability will be the focus of future enhancements of the electronic health record, which will support the health information exchange initiatives of the healthcare system and regional and national initiatives.
•It is important to note that these are typical functions
•Not all HIM departments are identical in organization or in the functions they perform
•Table 8.1 summarizes the some of the typical functions of the HIM department for paper-based and hybrid records and EHRs.
The medical training aspect of the facility adds another complicated dimension to the management of the health records
•Storage and retrieval of health records (including monitoring and tracking of health record location)
•Release of patient information
•Clinical coding of diagnosis and procedures
•Transcription of medical reports (excluding pathology and radiology)
•Statistical and internal report generation
•Cancer and trauma registry
•Records retrieved for patient care purposes, quality improvement studies, audits, and other authorized uses
•Records are delivered to the nursing units, outpatient surgery, and the emergency room as the patient is admitted or being treated
•Record is accessible to patient care areas via the computer by use of an electronic document management system (EDMS)
•If hospital is transitioning to the EHR, portions of the health record may be printed for use on the patient care unit
•The postdischarge order is usually different than the order of the record on the nursing unit
•After the record is assembled, it is analyzed for deficiencies, such as missing reports and signatures.
•Physicians visit the HIM department to complete deficiencies in records.
•The record is reanalyzed after completion to assure completeness of the process. Deficiencies are cleared from the computer
•Physicians complete the record from a computer that may be located remotely from the hospital.
•If electronic signatures, computer key, and electronic completion rules are applied, the deficiency system is updated once the physician completes his/her record
•Records are analyzed for deficiencies either manually by the HIM staff and/or by rules built into the computer system
•Physician dictates reports into a dictation system that records the voice. The transcriptionist types (transcribes) what the physician has dictated.
•The transcribed report is placed in the chart
•Reports commonly transcribed include: operative reports, history and physicals, discharge summaries, radiology reports, pathology reports, and consultations
•Speech recognition technology may be applied to the front-end and back-end of the transcription process to facilitate the process
•Logs and verifies validity of requests for patient information.
•May copy the record in response to valid requests or may provide record for an outsourced copy service to process.
•May go to court in response to a subpoena or court order.
•Must have in-depth knowledge of laws and regulations governing the release of information
•As the EHR evolves there may be opportunities for the HIM professional’s role to be expanded
•ICD-9-CM and CPT are the two primary coding systems used in a hospital setting. ICD-10-CM and ICD-10-PCS will replace ICD-9-CM
•Other information is abstracted from the record for reporting and reimbursement purposes
•Coding takes place on-site within the HIM department
•Coding may be remote to hospital; home-based coding is possible
•As the structure of the EHR evolves, computer-assisted coding may be utilized
•Data abstracting may be reduced or eliminated as automatic data capture is implemented
•Research and statistics
•Maintenance of cancer and other registries
•Support for medical staff committee functions
•Responsibility for birth certificate submission to state departments of public health
•Even though these functions may not fall within the traditional range of HIM department responsibilities, health information technicians (HITs) sometimes do perform them
•The MPI functions as the primary guide to locating pertinent demographic data about the patient and his or her health record number
•Without the information contained in the MPI, it would be almost impossible to locate a patient’s health record in most organizations that use a numeric filing system
•The MPI is the permanent record of every patient ever seen in the healthcare entity
•Patient’s health record number(s)
•Patient’s date of birth
•Dates of encounter (admission and discharge dates are usually maintained for inpatients)
•Additional information such as address, telephone number, and attending physician for each encounter also may be recorded in the index
•Figure 8.2 provides an example of an input screen for an electronic MPI system
•In addition, edit checks can be applied against specific fields in the database to better ensure data accuracy
•An electronic index also can be easily cross-referenced—for example, when a patient has used more than one name during hospital or clinic visits
•MPI cards are usually filed in strict alphabetical order in rotary files or vertical carousel storage files described previously
•A misfiled MPI card makes it almost impossible to locate a patient’s health record
•At the very least, record retrieval time is increased significantly
•This is why monitoring systems must be in place to ensure correct alphabetical filing of every card
•Many HIM departments have established a process whereby another employee rechecks every filed MPI card for proper alphabetical location
•For example, all MPI cards filed on the day shift are tagged and an employee from the evening shift rechecks the accuracy of each card’s location.
•This definitely slows down retrieval time. •Furthermore, updating, cross-referencing, and maintaining a manual system is more time-consuming than an automated system.
•These errors may include misspellings, incorrect demographic data, transposition of numbers, and typographical errors to name a few
•When the data integrity of the MPI has been compromised in this way the faulty data are dispersed throughout the organization risking treatment errors and billing problems, and distorting data analysis of the organization’s patient population (Dimick 2009)
•Duplicate, overlay, and overlap medical record number issues, discussed below, are significant problems
•To help mitigate these, some facilities have instituted registration improvement programs, which can feature cross-department committees whose purpose is to reduce registration errors and clean up the MPI (Dimick 2009).
•Performance of unnecessary duplicate tests
•Increased legal exposure in the area of adverse treatment outcomes
•This is called a duplicate medical record number and results in the creation of a new medical record.
•The situation in which a patient that already has a medical record number is assigned a new number.
•The consequence of this situation is that medical information from two or more individuals is comingled or combined, resulting in problems identifying what medical information belongs to which patient
•Overlaps may occur in organizations that have multiple facilities, such as a multi-hospital system, or can occur in health information exchanges
•Frequently this problem arises when there are facility or organization mergers and an enterprise master person/patient index (EMPI) is created
•MPI integrity, however, must be maintained in order to avoid patient safety, customer service, and risk management, legal, and other issues.
•Some of these may be input errors by personnel such as misspellings, typographical errors, and transposition of numbers among others
•Others may be retrieval errors such as using poor search strategies or reading errors
•And still others may be due to inaccurate information being provided by the patient or client
•This is generally done by a vendor who uses a sophisticated probabilistic algorithm that is based on complex mathematical principles to identify and fix these problems (Altendorf 2007)
•However, prevention of the problems should be the front line of defense
•There should also be standards in place for capturing and recording patient demographic data
•Quality improvement techniques should be implemented, such as benchmarking and performance standards (see chapter 11) and linked to employee productivity reports to hold staff accountable for accuracy (AHIMA MPI Task Force 2004)
•Policies and procedures such as those that identify MPI core data elements and their associated data definitions should also be established
•Advanced person search capabilities for minimizing the creation of new errors
•Mechanism for efficiently detecting, reviewing, and resolving potential errors
•Ability to reliably link different medical record numbers and other identifiers for the same person to create an enterprise view of the person
•Consideration of the types of physical merges (files, film, and so forth) and the interfaces and correction routines to other electronic systems that are populated or updated by the EMPI
•However, mechanisms must be in place to achieve this goal
•One common method is probabilistic matching that attempts to match an individual on multiple data elements such as name, date of birth, address, gender, and other items
•Probabilistic matching has been used in healthcare and other industries for decades
•These committees determine, for example, what data are used in the matching algorithm, how many potential candidate matches will be presented to the user, and data quality standards
•They are frequently members of data governance steering committees helping to define how patient identification is performed as well as addressing data security and privacy issues
•It is used as a unique personal identifier and is also used in paper-based numerical filing systems to locate records and in electronic systems to link records
•The HIM department also ensures that the identification numbering system is such that all of an individual patient’s records are stored together or can be linked together
•Patient care documentation generated as part of the patient’s episode of care is identified and physically filed or linked in an electronic system
•Thus, having a numbering system is important for efficiently storing and retrieving information about a single patient.
•The American Health Information Management Association (AHIMA) is in agreement on this issue due to privacy, confidentiality, and security issues related to the use of the SSN
•The system used determines the procedure for assigning the health record number and the method for filing the patient record in a paper-based system
•For example, Mr. Jones is admitted to the hospital at 8:00 a.m. on October 12 and given number 786544. Mrs. Wright, who registered at 8:15 a.m. on the same day, receives the next available number, 78654
•Thus, in a serial numbering system each patient receives the next available number in the series
•The information compiled for each admission is filed with the health record for each encounter
•One disadvantage to the serial numbering system is that information about the patient’s care and treatment is filed in separate health records and at separate locations
•This makes retrieval of all patient information less efficient and storage more costly
•Each time a patient returns to the healthcare facility, manual index cards or computer systems must be updated to reflect the addition of a new serial number and each update presents an opportunity for input error
•Many of the disadvantages to the serial numbering system can be addressed by using a unit number
•In the unit numbering system, the patient receives a unique health record number at the time of the first encounter
•For all subsequent encounters for a particular patient, the health record number that was assigned for the first encounter is used
•Having all the information related to the patient filed in one location facilitates communication among caregivers and improves operational efficiency
•For example, clerks in the admitting, emergency, and clinical departments must have access to a database of previous patients and their health record numbers
•Access to such information is not a problem for organizations that make the information available to the registration areas via a computer network and electronic MPI
•However, use of a manual system or an incomplete search of a computerized system increases the likelihood that duplicate numbers may be assigned to a patient
•Therefore, the unit numbering system generally works best in a computerized environment
•However, during each new patient encounter, the previous health records are brought forward and filed under the last assigned health record number
•This creates a unit record
•It also helps in addressing problems associated with retrieval and the cost of the serial system.
•In this system, the patient’s last name is used as the first source of identification and his or her first name and middle initial provide further identification.
•It is simple to locate a health record without first accessing an assigned number
•However, each entry must be double-checked to verify that the correct patient record is being used
•The patient account number and patient name are often used to find a patient’s health record stored electronically within a computer system
1. The system in which a health record number is assigned at the first encounter and then used for all subsequent healthcare encounters is the:
•Some organizations remain completely paper-based, while others use a combination of paper-based and electronic formats.
•The following section describes processes for the creation, storage, and maintenance of paper-based records
•Moreover, the data contained in patient health records are confidential; thus, mechanisms must be in place to ensure that only authorized individuals have access to them
•In paper-based storage systems, each health record is contained in a special file folder that is filed either alphabetically or numerically, depending on the size of the organization
•Clinics, hospitals, long-term care facilities, and other larger facilities file their records numerically, using the patient’s health record number as the primary identifier.
•Many large healthcare organizations are transitioning toward or have implemented electronically stored health records
•A hybrid record is a combination of paper-based and electronically stored health data
•The hybrid record environment includes a combination of paper-based and EHR systems
•Filing systems for paper-based health records
•Retrieval and tracking systems
•Likewise, the patient’s name is used as the basis for filing in an alphabetical filing system
•The HIM department must carefully consider the types of filing and storage systems it uses to ensure that they meet the needs of the organization
•The three major classifications of filing systems are discussed below
•This system is usually satisfactory for a very small volume of records, such as records maintained in small physician practices
•The alphabetic filing system is easy to create and use
•It is often called a direct filing method because it does not rely on an index or an authority file and the user can find a file by looking directly under the name of the record
•For example, a large facility may have several patients named Paula Smith
•If it were relying strictly on alphabetical filing by patient last and first name, multiple health records would be labeled Paula Smith on the file shelf
•Statistically, almost half the files fall under the letters B, C, H, M, S, and W
•With an alphabetical filing system, each individual record needs to be checked for the last patient encounter to determine whether it is inactive (figure 8.3).
Brown, Michelle L.
S. Brown, Robert A.
When the patient has identical last and first names and middle initial, order the records by date of birth, filing the record with the earliest birth date first
For example, the names Mackel, Mac Bain, and Mc Dougal would be filed as:
•Numeric filing is a type of indirect filing system
•The filing clerk searches the MPI by patient name
•When the correct patient is located in the MPI, the clerk uses the health record number to locate the patient’s health record folder within the filing system
•However, in larger organizations, the numeric filing system actually has many advantages over an alphabetic system
2. The terminal-digit filing system
3. The middle-digit filing system is very similar to the terminal-digit filing system.
•In this system, the last digit or group of last digits (terminal digits) is the primary unit used for filing, followed by the middle unit and the last unit of numbers
•For example, 443798 could be broken down as 44-37-98, with 98 as the primary unit for filing, 37 as the secondary (middle) unit, and 44 as the tertiary unit
•The record would be filed in the following arrangement: file section, 98; shelf number, 37; and folder number, 44. An example of how health records are filed using terminal-digit filing is shown in figure 8.4.
•Note: Records first are filed by the last two digits, then the middle two digits, and finally in numerical order by the first two digits
•This is because large numbers can be divided into groups of several digits and still be easily managed for filing and retrieval purposes
•In addition to ensuring that every record has a unique number, terminal-digit filing allows even file expansion, unlike an alphabetic or straight numerical filing system
•The middle-digit filing system is very similar to the terminal-digit filing system
•The primary unit is the middle unit, the secondary unit is the first unit to the left, followed by the last digits
•For example, 443798 could be broken down as 37 as the primary unit, 44 as the secondary unit, and 98 as the tertiary unit
•The record could be filed in the following arrangement: file section, 37, shelf number, 44; and folder number, 98
•For example, one healthcare facility may have a health record number that is six digits in length
•The highest number or volume of records that could be accommodated in such a numbering scheme would be 999,999 records
•Some facilities may have a three-digit primary unit.
•However, the method for filing would remain the same. The file section corresponding to the primary unit would be accessed first, followed by the secondary unit, and then the tertiary unit.
Numeric Filing Systems
Alphanumeric Filing Systems
•The first two letters of the patient’s last name are followed by a unique numeric identifier
•The alphanumeric filing system is appropriate for small organizations
•Although this system may be quicker because file clerks first file the record alphabetically, it still relies on accessing a master index or authority file to identify the unique numerical number
•The unique identifier can be alphabetic, alphanumeric, or numeric
•For example, in a small medical practice all of an individual’s encounters may be filed together alphabetically by last name
•In addition, the supply costs for record folders are reduced because all forms and information are filed together in one folder
•Furthermore, computer or index card update issues are lessened using the unit numbering system
•The patient retains the same health record number, regardless of the number of admissions or encounters.
1. Consider the following sequence of numbers: 12-34-55, 13-34-55, and 14-34-54. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system?
2. The master patient index (MPI) is necessary to locate health records within the paper-based storage system for all the types of filing systems, except:
3. The term used to describe a combination of paper-based and electronic health records is:
4. Which of the following is an advantage of a centralized unit filing system?
5. Which filing system is considered to be the most efficient?
•Paper-based records are stored in filing cabinets or shelving units
•Other storage options include microfilm, off-site storage, and imaged-based storage
•As healthcare facilities transition toward and implement the EHR, imaged-based systems are increasingly utilized.
•For organizations with a high record volume, a combination of systems may be the appropriate choice
•For organizations that have a very low volume of records, paper storage may be appropriate
•Vertical file cabinets are the traditional drawer files and come in sizes that can hold either letter or legal-sized records
•The usual configuration is two or four drawers
•Vertical file cabinets are appropriate for low-volume record storage
•However, this type of filing equipment does not facilitate quick and easy filing and retrieval
•Therefore, these file cabinets are rarely used to store health records
•However, the drawers open laterally rather than vertically
•They also include side-to-side rails for hanging files.
•These filing units range in size from two to five drawers and are usually 30 or 36 inches in width
•Although easier for retrieval and filing than vertical cabinets, this type of equipment would only be used in low-volume offices
•Shelf files resemble open bookshelves
•They can either be totally open or have receding doors
•Shelf files are ideal for high-volume record storage
•Shelving units with six shelves are usually used for record storage purposes
•Moreover, shelf files save space
•For example, one six-shelf unit offers file capacity equal to eight 30-inch-wide lateral file drawers
•Instead of having aisle space between every row of files, mobile files conserve floor space by providing only one aisle of space
•This is accomplished by mounting the file shelves on tracks secured to the floor
•The shelves then are moved by hand, with mechanical assistance, or electronically
•This type of storage system is ideal in facilities where space is a major concern
•In most situations, an organization can double or even triple storage capacity in the same floor space, even when compared to other, high-density filing systems such as open shelf
•This filing system consists of stationary shelving in the back and file storage shelving that slides side to side in the front
•This is an inexpensive way to increase the storage capacity of existing shelving or another record storage system
•However, this type of shelving is only appropriate for low-volume record filing and retrieval activity
•The horizontal carousel contains open-shelf files that revolve around a central spine or track system
•Essentially, this type of filing system brings the files to the user, thus avoiding walking through aisles of files
•The vertical carousel system brings all files or records to a standing or sitting workstation and can take advantage of vertical ceiling height
•Vertical carousel systems are often used to store the manual MP
•How frequently paper-based records are purged from the storage system is determined by not only space availability, but also the patient readmission rate and the use of patient record data
•For example, a research hospital may maintain health records in paper format for a period of time longer than other facilities because researchers may need to access information about patients who have expired or who have not been admitted to the facility for a number of years
•Over a year, this amounts to 36,500 new records
•If approximately one inch is required to store five paper records, the organization would need approximately 7,300 inches, or approximately 608 feet, of filing space.
•This involves analyzing the volume indicators, such as number of discharges, size of the records, and filing inch capacity of the storage unit
•For example, one could estimate the number of shelving units required by using the following information:
Shelving unit shelf width = 36 inches
Number of shelves per unit = 7 shelves
Average record thickness = ½ inch
Average annual inpatient discharges = 8,500 patients
36 inches per shelf × 7 shelves per unit = 252 inches per shelving unit
2. Determine the linear filing inches needed for the volume of records.
8,500 average annual inpatient discharges × ½ average record thickness = 4,250 filing inches required to store one year of inpatient discharge records
3. Determine the number of shelving units required by dividing the required filing space by the shelving unit linear inch capacity.
4,250 ÷ 252 = 16.8 shelving units
•However, most HIM departments store more than inpatient discharge records
Hospital XYZ has the following volume statistics:
Average inpatient discharges per year = 10,000
Average inpatient record thickness = 1 inch
Average outpatient visits = 22,500
Average outpatient record thickness = ¼ inch
Each shelving unit has 7 shelves, each 36 inches wide
10,000 inpatient discharges per year × 1 inch = 10,000 linear filing inches required
22,500 outpatient visits per year × ¼ inch = 5,625 linear filing inches required
10,000 + 5,625 = 15,625 linear filing inches needed for inpatient and outpatient records
2. Determine the linear filing inches per shelving unit.
36 inches per shelf × 7 shelves per unit = 252 inches per shelving unit
3. Divide the required filing space by the shelving unit linear inch capacity.
15,625 inches needed ÷ 252 inches per shelving unit = 62 shelving units required to store the records
•Therefore, for this example 62 shelving units would be required to store one year of records
•During an average inpatient encounter, a health record exceeding 100 pages is common
•These various reports and documents must be sorted and stored in their own file folders. File folders come in two standard weights, 11 and 14 point
•Higher weights such as 20 point are also available
•The higher weight is the most durable and would be the folder of choice for active records that receive heavy filing and retrieval activity.
•Side-tab folders, which are the usual configuration for health records, are used in all open-shelf filing systems
•They can be placed at the top or sides of the file folder
•Usually, folders are purchased with fasteners attached, although for low-volume operations self-adhesive fasteners can be used and installed by office staff
•Dividers also may be placed in health records to separate clinical, inpatient, outpatient, and/or administrative documents
•For example, in a numeric filing system, each single digit is a specific color
•Therefore, one can easily locate misfiles by visually scanning a shelf for disruption of the color pattern of a particular file shelving section
•For lower-volume systems, color-coded labels can be affixed to the file folders.
•There are other options for record storage that significantly reduce space needs
•A traditional alternative that has been used over the past three or more decades is micrographics or microfilm
•Microfilm is a good storage alternative for inactive or infrequently used health records
•Because the images are so small, a special microfilm viewer or reader that magnifies each image must be used to read them
•One roll of microfilm can potentially hold thousands of images and the health records of hundreds of patients
•However, the fact that the roll stores document pages sequentially can be a disadvantage
•For example, if the organization is using a serial numbering system, a patient’s entire health record covering multiple encounters may be on separate roles of microfilm
•This makes retrieval less efficient
•A benefit of this option is that all the patient’s records can be collected together in the same jacket or several jackets can be combined in a small paper folder
•Thus, the record becomes a unit record holding all information about the patient
•Jackets can be color-coded with the patient’s health record number and name. They are usually filed using the same type of filing system (alphabetic, straight numerical, terminal digit) used for paper files
•It is made on Mylar film and is the same size as the microfilm jacket •When used as a copy from the source health record, the microfiche eliminates the need to cut rolls of film to fit into microfilm jackets
•Sometimes organizations store their health records in microfilm jackets •These jackets are never removed from the HIM department
•Instead, when the information is needed, a microfiche copy is made using a special duplicator and then provided to the requesting care areas
•Moreover, microfilm is acceptable as courtroom evidence and provides good security because it is difficult to tamper with
•The company then retrieves and delivers records requested by the healthcare facility’s HIM department for a fee
•The healthcare facility should carefully evaluate the off-site storage company’s capabilities for storing records securely for the entire retention period
•Essentially, a document imaging system scans and indexes an original source document to create a digital picture that can be retrieved via the computer
•When scanned, the images are stored on electronic media, such as a magnetic or optical disk
•Unlike microfilm rolls, the optical disk is a random-access device and retrieval of documents is much faster
•Additionally, document images can be viewed by more than one person at one time and at different locations
•Moreover, it saves money by reducing the need for storage space and by decreasing the work of file clerks
1. What type of paper-based storage system conserves floor space by eliminating all but one or two aisles?
2. What feature of the filing folder helps locate misfiles within the paper-based filing system?
3. In a paper-based system, the HIM department routinely delivers health records to:
4. Which of the following paper weights would be the most durable for the medical record folder?
5. What microfilm format is inefficient when patients have multiple admissions on microfilm?
•An outguide is usually made of strong colored vinyl with two plastic pockets
•It is the size of a regular record folder and is placed in the record location when the record is removed from the file
•The larger of the plastic pockets is used to hold loose reports or other documents that come to the HIM department while the original record is charged out
•The smaller pocket is used to house information about who checked out the health record, its current location, when it was checked out, and the expected return date
•This checkout information may be either a handwritten or computerized requisition slip generated from a tracking system
•Request from a clinical or other area in the organization to charge out a specific health record
•The information contained on a requisition usually includes patient’s name, health record number, date of the request, date and time needed, name of the requestor, and location for delivery.
•One copy is the routing slip that comes with the health record
•Another copy goes in the outguide
•A third copy may be used as a transfer notice and sent to the HIM department if the health record is subsequently transferred to another location
•For example, if a record were requested from the intensive care unit (ICU), it would be transferred to the medical unit when the patient was transferred from the ICU to the medical floor
•Automated systems such as these are similar to a library book checkout system
•With an automated system, it is easy to track how many records are charged out of the HIM department at any given time, their location, and whether they have been returned on the due dates indicated
•The HIM department should create facility-wide policies and procedures for the proper use of tracking systems •Further, an audit for health records not returned in a timely manner should be performed on a regular basis.
•Retention policies and procedures relate to what information must be retained, for how long, and in what form. Destruction policies and procedures relate to what information may be destroyed, appropriate destruction methods, and required documentation of destruction
•Each healthcare provider should develop a retention schedule for patient health information that meets the needs of its patients, physicians, researchers, and other legitimate users, and complies with legal, regulatory, and accreditation requirements
•The retention schedule should include guidelines that specify what information should be kept, the time period for which it should be kept, and the storage medium (paper, microfilm, optical disk, magnetic tape, or other)
—Compliance programs should establish written policies to address the retention of all types of documentation
•This documentation includes clinical and medical records, health records, claims documentation, and compliance documentation
•Compliance documentation includes all records necessary to protect the integrity of the compliance process and confirm the effectiveness of the program, including employee training documentation, reports from hotlines, results of internal investigations, results of auditing and monitoring, modifications to the compliance program, and self-disclosures
—The documentation should be retained according to applicable federal and state law and regulations and must be maintained for a sufficient length of time to ensure its availability to prove compliance with laws and regulations.
—The organization’s legal counsel should be consulted regarding the retention of compliance documentation
•In the absence of specific state requirements for record retention, providers should keep health information for at least the period specified by the state’s statutes of limitations or for a sufficient length of time to prove compliance with laws and regulations
•If the patient was a minor, the provider should retain health information until the patient reaches the age of majority (as defined by state law) plus the period of the statute of limitations, unless otherwise provided by state law
•A longer retention period is prudent, since the statute may not begin until the potential plaintiff learns of the causal relationship between an injury and the care received. In addition, under the False Claims Act (31 USC 3729), claims may be brought for up to 7 years after the incident; however, on occasion, the time has been extended to 10 years
Diagnostic images | 5 years
(such as x-ray film)
Disease index | 10 years
Fetal heart monitor records | 10 years after the infant reaches the age of majority
Master patient/person index | Permanently
Operative index | 10 years
Patient health/medical records (adults) | 10 years after the most recent encounter
Patient health/medical records (minors) | Age of majority plus statute of limitations
Physician index | 10 years
Register of births | Permanently
Register of deaths | Permanently
Register of surgical | Permanently
•Furthermore, records involved in any open investigation, audit, or litigation should not be destroyed
—Appropriate methods for destroying paper records include burning, shredding, pulping, and pulverizing
—Methods for destroying microfilm or microfiche include recycling and pulverizing
—The laser disks used in write once-read many (WORM) document imaging applications cannot be altered or reused, making pulverization an appropriate means of destruction
—The preferred method for destroying computerized data is magnetic degaussing
•(Data are stored in magnetic media by making very small areas called magnetic domains change their magnetic alignment to be in the direction of an applied magnetic field
•Degaussing leaves the domains in random patterns with no preference to orientation, rendering previous data unrecoverable.)
•Proper degaussing ensures that there is insufficient magnetic remanence to reconstruct the data. Overwriting can also be used to destroy computerized data. (To overwrite, cover the data with a pattern, its complement, and then another pattern—for example, 00110101, followed by 11001010, and then 10010111.)
•In theory, however, files that have been overwritten as many as six times can be recovered. Total data destruction does not occur until the original data and all backup information have been destroyed
—Although magnetic tapes can be overwritten, it is time consuming and there can be areas on a tape that are unresponsive to overwriting
•Degaussing is considered preferable
—Date of destruction
—Method of destruction
—Description of the disposed records
—Inclusive dates covered
—A statement that the records were destroyed in the normal course of business
—The signatures of the individuals supervising and witnessing the destruction
•These are called certificates of destruction
•Such certificates may be required as evidence to show records were destroyed in the regular course of business
•When facilities fail to apply destruction policies uniformly or where destruction is contrary to policy, courts may allow a jury to infer in a negligence suit that if records were available, they would show the facility acted improperly in treating the patient
•Figure 8.8 provides an example of a certificate of destruction
—Indemnify the healthcare facility from loss due to unauthorized disclosure
—Require that the business associate maintain liability insurance in specified amounts, at all times the contract is in effect
—Provide proof of destruction
—Specify the method of destruction
—Specify the time that will elapse between acquisition and destruction of data
1. Under the False Claims Act, claims may be brought up to how many years?
2. Record retention should be based on:
3. Which of the following is the appropriate method for destroying microfilm?
4. Which of the following is the appropriate method for destroying computerized data?
5. The tool used to track paper-based health records is:
•The quality of patient care is adversely affected when complete and correct information is not readily available for delivery of patient care
•Moreover, administrative and other functions, such as evaluating clinical quality performance, billing, and research, would be negatively affected without a complete and accurate health record
•The following activities are normally considered record processing.
•However, before health records can be processed, the HIM professional must assure that all health records for patients discharged on that date have been received
•The health records received by the department are compared to a discharge list, which is usually generated from the hospital’s registration system
•The process of assuring that all the records of discharged patients have been received by the HIM department for processing is called record reconciliation
•The chart-tracking system is updated to reflect that old records have been returned and filed in the permanent file area
•The current records of discharged patients are then sent to the health record processing area
•Assembly means that each page in the patient record is organized in a pre-established order
•The pre-established record order of the pages varies from facility to facility
•Each page in the patient record is reviewed to ensure that it belongs to that record
2. Retrospective review
•Using this method, personnel from the HIM department go to the nursing unit daily (or periodically) to review each patient’s record
•This type of process is usually referred to as a concurrent review because review occurs concurrently with the patient’s stay in the hospital
•This type of review is called retrospective review because it occurs after the patient has left the facility
•In this process, the patient’s health record is received in the HIM department, usually the day after discharge, and reviewed by an HIM professional
•The part of the utilization review process that concentrates on a review of clinical information following patient discharge
•All forms and reports are present. For example, when the patient is admitted for a cholecystectomy, a minimum set of operative reports, consents, and forms should be present (operative consent form, anesthesia form, operative report, recovery room report, pathology report, and so on)
•Reports requiring authentication (that is, operative, pathology, discharge summaries, history and physicals, and radiology reports) have signatures or have been appropriately authenticated
•See figure 8.9 for a sample paper deficiency slip
•Usually, the deficiency slip is a multipart form, one copy appended to the health record and one or more copies filed by physician name
•A record with deficiencies is called an incomplete record
•This type of system stores the entered data into a database for later retrieval or analysis
•When deficiencies are identified and documented, they must be corrected. When reports or forms are missing, HIM personnel should try to locate them.
•Other inpatient facilities, such as long-term care and rehabilitation institutions, usually follow the same processes as acute care facilities
•Outpatient facilities such as clinics or physician office practices usually conduct a quantitative analysis after each patient visit or on a periodic basis
•In a paper-based system, the medical record must be located and the loose report assembled into the appropriate location within the record
•Periodically, the HIM department notifies the appropriate individuals of the incomplete or deficient record status and requests that they come to the department to rectify it
•In the EHR environment, or where electronic signatures and electronic authentication of medical records is accepted, the incomplete record file may be eliminated.
•If no deficiencies are found, the deficiency slip is removed and/or the deficiency tracking system is updated to reflect that the health record is completed
•The health record then is routed to the storage and retrieval area for filing in the permanent file
•The HIM department monitors the delinquent record rate very closely to ensure compliance with accrediting standards that define performance expectations or processes that must be in place
•Regardless of the media used to store the health record, policies must be in place to assure the integrity of the information contained in the health record as a business record, legal health record, and as a patient care communication tool •The healthcare facility must have written policies that specify who, when, and how amendments, corrections, and deletions may be made to a health record
•Error: correction “female” Jane Smith, MD 12/11/09 15:00
•The 72-year-old white male presents to the emergency room with a 4-hour history of severe lower right quadrant abdominal pain
•In this type of correction, a previous entry has been made and the addendum provides additional information to address a specific situation or incident
Write “addendum” and state the reason for the addendum, referring back to the original entry
•Identify any sources of information used to support the addendum
•When writing an addendum, complete it as soon after the original note as possible
•An amendment must be dated, timed and signed and attached to the original document that it is amending (Hall et al. 2009)
•For example, HIM professionals responsible for release of information would be granted the right to print the EHR or copy the paper record, whereas a nurse or physician would be granted view-only access to the EHR
•Physicians and nurses would be granted the right to enter patient information in the EHR
•Checking a photo identification card (for example, employee identification card) is one example of authentication of the person’s right to access the paper-based health record
•Access cards may also be used to authenticate the user’s right to access the record system
•Access cards are often used in combination with passwords or personal identification numbers (PINs) as a method of authenticating the person’s identity (AHIMA Workgroup on Electronic Health Records Management 2004)
•In a paper record system, forms make possible the capture of adequate healthcare documentation
•The HIM department often participates in forms design in consultation with a forms vendor
•This means that the form must fulfill its intended purpose, include all the necessary data, and be easy to use
•This basic information will drive the rest of the design process
•For example, when the purpose of the form is to meet a licensing requirement, the data elements contained on it must comply with the requirement
•When the form is to be used by multiple individuals, a multicopy version might be appropriate. When it is to be completed by hand, it must allow enough space for handwriting
•Each form should include original and revised dates for the tracking and purging of obsolete forms.
•Each form should have a concise title that clearly identifies the form’s purpose.
•The facility’s name and logo should appear on each page of the form.
•For clinical forms, patient identification information (name, health record number, billing number, physician name and number, date of birth, admission date, and room number) should appear on every page.
•For clinical forms, a signature line should appear at the bottom, and there should be no question about what has been authenticated. If initials are used, space also should be provided for the full name and title so that each set of initials is identified
•Data-entry methodology should be considered when the information is to be keyed into a computer. The order of the form should mirror the data-entry order to ensure that information is entered consistently.
•Optical character reader codes and barcodes should be printed in the upper left-hand corner of the form when imaging the health record is a possibility.
•A standard of 8.5 by 11 inches is the best size for a document. Bifold and trifold documents are difficult to handle and copy in a closed chart.
•Form colors should be black ink on white paper. If color coding is desired, a strip of •Documents that contain punched holes should have a margin of at least 3/4 inch. All other margins should be at least 3/8-inch wide.
•Vertical and horizontal lines assist the user in completing and reviewing the form. Bold lines should be used to draw the reader’s eye to an important field.
•Sufficient space should be provided to complete the entry (for example, 1/16 inch for typed letters and 1/3-inch high for handwritten entries).
•Titles for boxes and fields should be located in the top left-hand corner of the box or field.
•Paper ranging from 20 to 24 pounds in weight is recommended for use in copiers, scanners, and fax machines.
•Type size should be no smaller than 9 points for lowercase letters and 10 points for uppercase letters
•For example, the use of colored paper or ink other than black should be minimized or eliminated because the color can adversely affect the quality of the scanned images
•Forms not containing a barcode must be indexed separately when scanned into the computer
•The medical records committee also may function in this capacity
•This committee should provide oversight for the development, review, and control of all enterprise-wide information capture tools, including paper forms and design of computer screens
Support or ancillary departments
Forms vendor representative
•For example, when a form is being redesigned for use in the intensive care unit, nurses or physicians from that clinical area should be invited to give their input
•Written standards and guidelines are essential to ensure that good design and production practices are followed
•A forms manual should be developed. Standards are fixed rules that must be followed for every form (for example, where the form title should be located)
•A guideline, on the other hand, provides general direction about the design of a form (for example, usual size of the font used)
2. Establishing a numbering and tracking system:
•A unique numbering system should be developed to identify all organizational forms
•A master form index should be established, and copies of all forms should be maintained for easy retrieval
•At a minimum, information in the master form index should include form title, form number, origination date, revision dates, form purpose, and legal requirements. Ideally, the tracking system should be automated
3. Establishing a testing and evaluation plan:
•No new or revised form should be put into production or use without a field test and evaluation
•Mechanisms should be in place to ensure appropriate testing of any new or revised form
4. Checking the quality of new forms:
•A mechanism should be in place to check all newly printed forms prior to distribution
•This should be a quality check to ensure that the new form conforms to the original procurement order.
5. Systematizing storage, inventory, and distribution:
•Processes should be in place to ensure that forms are stored appropriately
•Paper forms should be stored in safe and environmentally appropriate environments
•Inventory should be maintained at a cost-effective level, and distribution should be timely
6. Establishing a forms database:
•In an electronic system that supports document imaging, a forms database may be used to store and facilitate updating of forms
•Such a database can provide information on utilization rates, obsolescence, and replacement of individual forms or documentation templates
•Further, having good forms design practices does not necessarily mean that all forms that are developed are necessary
•The strategies discussed thus far help ensure quality control over the management of health record content
•After quality control standards are established, it is important to establish a monitoring system to determine whether goals are being met
•Corrective action should be implemented when error or accuracy rates are deemed to be at an unacceptable level. Chapter 11 describes specific techniques and quality improvement practices
•To conduct a study, a section of the permanent file room can be checked for misfiles
•Any misfiles found are noted, and a filing accuracy rate can be determined and compared against the established standard
•For example, if the standard is that “99 percent of the health records will be filed correctly,” a sample of filed records can be checked for misfiles
•If 550 health records are checked and 7 misfiles are found, the error rate is 1.27 percent (7 divided by 550 multiplied by 100, which would make the accuracy rate 98.7 percent)
•Records for the emergency department will be retrieved within 10 minutes of the request
•Loose materials will be filed in either the record or the outguide pocket within 24 hours of receipt in the HIM department
•An average of 190 pages of scanned records will be indexed in an hour
•Scanned records will be available online within 24 hours of discharge
•If records are unavailable when they arrive, the chart completion process is delayed
•For example, if seven physicians worked on completing charts on a particular day with a total of 210 incomplete records collectively and a total of 35 charts were not available, the nonavailable chart rate is 16.6, or 17 percent (35 divided by 210 multiplied by 100)
1. What should be done when the HIM department’s error or accuracy rate is deemed unacceptable?
2. The forms design committee:
3. Statements that define the performance expectations and/or structures or processes that must be in place are:
4. In a paper-based system, individual health records are organized in a pre-established order. This process is called:
5. Reviewing a health record for missing signatures and missing medical reports is called:
6. Reviewing the record for deficiencies after the patient is discharged from the hospital is an example of what type of review?
7. Incomplete records that are not completed by the physician within the time frame specified in the healthcare facility’s policies are called:
9. __F__ Addendums should document the date the event actually happened—not the date it was documented.
10. _T___ The best practice for forms design is to use white paper with black ink
•For example, dictation, laboratory, and x-ray results might be available electronically, whereas progress notes, ancillary care, provider information, graphic sheets, and doctors’ orders remain on paper
•This information in the health record is collected and/or directly used to document healthcare delivery or healthcare status
•Dictation or transcription, laboratory results, and radiology reports are often the first components to be accessible electronically
•The following sections describe in additional detail the management of the hybrid record
•This is due in part to the different media and technologies used that require different work functions and workflow patterns
•An EDMS encompasses a wide range of technologies used to provide portions of an electronic health record and does more than manage documents after they are scanned into the computer
•Scanning a paper document and creating a digital image
•Using workflow management technologies to schedule and monitor work tasks
•Using multimedia technologies and formats and using technology to move computer generated content such as a history and physical or discharge summary from a transcription system to an EDMS without creating paper
•Figure 8.12 provides a checklist of key steps in the planning process for an EDMS
•Index and perform quality control after documents are scanned
•Indexing is performed to assign document names and encounter numbers to each document
•Quality control is performed on 100 percent of images to review the quality of the scan
•In addition to this initial quality control, ongoing quality monitoring should be performed on a random basis
•The information stored is the entity’s business record (in healthcare, the legal record)
•A plan to house this information on media other than paper must be scrutinized by legal counsel to ensure that the technology being considered can comply with federal and state laws, requirements for licensure, and credentialing along with operational needs and that it is consistent with existing policies and procedures
•There should also be a risk management component to ensure that there will be no compromise to patient care and that documents required for lawsuits remain available
•This latter consideration may impact a facility’s decision on how to proceed with their documents once scanned into the imaging system
2. The incomplete record area resides in the EDMS
3. Medical coding may be done remotely
•Additionally, checks are made to ensure that all pages are identified accurately as part of the individual patient’s record •Depending on the extent to which barcoded forms are used, the record may still need to be assembled to ensure proper order by date and type of report. •The record is then scanned using highspeed scanners
2. Record receipt is reconciled with the list of patients discharged for that date.
3. Records are prepared by removing staples, clips, and repairing torn pages.
4. Each page of the record is checked to verify that it does indeed belong to that patient
5. Record is scanned into the EDMS.
6. The quality of the scanned image is reviewed. If the image is not of high quality, the image is enhanced or rescanned
7. Forms missing a barcode are indexed and placed into the proper location within the health record
8. Records are analyzed for missing documents (for example, discharge summaries, operative reports, history and physicals, and so forth)
9. Records are analyzed for missing signatures. Deficiencies are electronically tagged
10. The record is sent to an “incomplete” work queue for the physician to complete.
12. When the record is completed, it is locked to prevent further changes to the health record
13. Scanned paper records are boxed or sent to storage and kept for the period specified in the record retention policy.
•For example, in management of record completion, as the status of dictation changes from dictate to transcribe to sign to signed, the status of the deficiency system is automatically updated without human intervention
•At the same time, a request for dictation or review and signature is routed to the physician’s in-box
•The healthcare facility must consider state and federal regulations, statutes of limitation, research and educational needs, and patient care needs
•The facility must have a policy on how long the paper portion of the imaged record is maintained after the record is complete
•Other facilities may decide to maintain the paper records of imaged documents for longer or shorter periods of time
•The storage capacity, the cost, and the definition of the facility’s legal record will determine how long these paper records are maintained.
•The decision may be made by the facility to maintain the fetal monitoring strips and other like documents on paper and store them within the facility
•The location and existence of these paper portions of the record must be noted in EDMS
•Policies must be in place to assure the integrity of the information contained in the health record as a business record, as a legal health record, and as a patient care communication tool
•If the record is in paper format then the guidelines discussed earlier under paper-based systems apply
•If the record is in an electronic format then the guidelines discussed in the following section under electronic record systems apply
•Records stored in EDMSs present unique situations for handling corrections
•Facilities should develop guidelines for changes made to signed and unsigned documents
•For example, if a document is changed or corrected, typically the copy with the error is removed from view within the EDMS
•However, a copy of the original document must be available. This can either be a manual or electronic process •It is important that all staff are aware that these documents are available. Some type of annotation may be made in the EDMS system so that clinical staff will know who to contact if they feel they may need to see the original document
•In the record from which the document was removed, the document would NOT be considered part of the designated record set or visible to anyone
•Someone should be designated by the organization to view or print the retracted documents
•An annotation should be viewable to the clinical staff so that the retracted document can be consulted if needed.
•As with retractions, someone in the organization should be designated to view or print the reassigned document
•An annotation should be viewable to the clinical staff so that the reassigned document can be consulted if needed
•The goal of the hybrid record system is to enable retrieval of information to assist healthcare professionals in providing quality patient care and reporting patient outcomes
•In these cases the facility will have to rely on usual paper-based location identification and retrieval processes.
•For example, retrieval could be through the organization’s intranet, the Internet, an application on the desktop, or within the clinical system
•Access should be integrated so that the end user does not have to move between various systems
•To ensure that the right information is delivered to the right person, the system should provide basic and advanced search methods that include filters as well as security measures that track access and limit access on a need-to-know basis
•Auto fax for authorized users
•Remote viewing should be provided to authorized individuals and should use customary security processes for remote access
•Remote viewing may include viewing documents from physician offices and for remote record completion or remote coding to name a few instances
•Since the hybrid record is comprised of both paper and electronic components, the healthcare facility must address authorization to access both the paper and electronic portions of the record.
•The most common method of authentication is the use of user names and passwords
•Access control is strengthened by the use of “strong” passwords that include numbers, upper- and lowercase letters rather than easily identifiable names or numbers
•Nonrepudiate means to accept
•An example of a nonrepudiation measure is the use of electronic signatures to assure the authorship of a record entry in which rules built into the EHR will date and time stamp the entry and then lock the notation or report to prevent future changes to the original information documented in the record
2. Reconciliation in the Hybrid Record
•Each page of the health record must be checked prior to document scanning to verify that it belongs to that patient’s record
•After the record is scanned, the images are often reviewed to ensure that a high-quality image has been achieved
•If an image is found to be unclear, the document is rescanned after adjustments are made to the computer or scanner.
•Record processing is also monitored to assure that records are processed in a timely manner and meet standards set forth by the healthcare facility
•For example, a healthcare facility may have a standard that all records for discharged patients are scanned and available in the EDMS for completion within 24 hours of discharge
•The HIM professional may monitor the health records processed on a daily basis to determine if this standard is being met
•In paper-based systems, reconciliation usually is incorporated into the chart analysis process
•In a hybrid record system, reconciliation may be even more challenging because data are being captured from a variety of sources and moving across interfaces. •Figure 8.13 provides a comparison of reconciliation quality control tasks across paper-based, hybrid, and electronic health record systems
Paper systems: Verify that a record exists for each discharge. Verify correct patient type registered (for example, inpatient, short stay, observation status) to ensure accurate billing
Hybrid or Transitional Systems: Same with addition of monitoring canceled admits.
Full Electronic Systems: SAME
Paper systems: Verify that record exists for every registration. Verify correct registration of multiple visits in one day according to APC regulations.
Hybrid or Transitional Systems: Same with addition of monitoring canceled admits.
Full Electronic Systems: SAME
•The policies defining the legal health record must be updated as the paper-based component and functions transition into electronic formats
•The policies must clearly identify what components will be disclosed upon request
•The management of the health record may be challenging as paper and electronic work processes coexist
•Health records may still need to be assembled to some degree before scanning and imaging can be done •Additionally, when scanning and imaging are part of the hybrid record process, there is a cost associated with the existence of paper records and the cost of imaging equipment to provide an electronic view of the health record
•Paper records still need to be retrieved from patient care units and then reconciled with discharged patient lists to assure that all health records are received in preparation for the scanning process
•The HIM professional must be a change agent in the process and recognize that the transition to an electronic health record will be easier for some than others. Not all clinicians embrace the use of technology and some may be reluctant to use the new technology
1. Which of the following chart-processing activities is eliminated with an EHR that uses scanned images?
2. One of the advantages of an EDMS is that it can:
3. Which term indicates that a document has been removed from standard view?
4. Which term is the process of checking individual data elements, reports, or files against each other to resolve discrepancies?
5. Which of the following could be used to determine if someone has the right to view a health record?
•The EHR automates and streamlines the clinician’s workflow
•The EHR has the ability to generate a complete record of a clinical patient encounter—as well as supporting other care-related activities directly or indirectly via interface—including evidence-based decision support, quality management, and outcomes reporting
1. To provide clinical decision support;
2. To support physician order entry;
3. To capture and query information relevant to healthcare quality; and
4. To exchange electronic health information with and integrate such information from other sources.
•Both paper and electronic components comprise the hybrid record
•Important to remember that the EHR is really just automation, not a magic bullet
•If a hospital has poor workflow processes, migrating to electronic records will simply automate those poor processes, not solve them. •Therefore, re-engineering manual systems and processes represents a major opportunity for reducing costs, improving service and establishing the correct infrastructure to transition to the automated hospital record
•Defining the facility’s legal record
•Standardization of forms and processes
•Development of a forms catalog or inventory
•Barcoding of forms
•Criteria development for hardware, software, and vendors
•Privacy and security procedure establishment
•Training of staff and medical staff
•Issues related to the planning, design, development, implementation, and maintenance of information systems including vendor selection processes are explained in Chapter 15.
•As data are increasingly captured and entered into the computer at the point of care, paper documentation is greatly reduced and therefore the need to file the record is either reduced or eliminated
•The function and content of audit trails are discussed in chapter 15
•Health records with deficiencies assigned to multiple physicians for completion are completed in a more timely manner in the EHR environment because more than one person can access the record from assigned work queues. •Health records can be routed to the medical coding queues at the same time the records are available for completion in the record completion queues, thus facilitating the medical coding and billing process
•One example where multiple versions could exist is in an electronic health record where there is a medical report that is unsigned and then the physician signs the report
•This represents two versions of the same document, one signed and the other unsigned. •Similarly, when a physician makes changes to a health record or amends it, multiple versions of the document exist
•Each healthcare facility must have policies and procedures for version control stating which versions of the document will be viewable within the health record
•Documents must be “flagged” when an earlier version of a document exists and the date and time of the availability of each version of the document must be clearly documented
•The nature of free text is that it is undefined, unlimited, and unstructured. For these reasons, it is more difficult for a search engine to find, retrieve, and manipulate data than structured text.
•Many of the advantages of manipulation of data that the EHR offers are lost when the health record is comprised of large amounts of unstructured data.
•The use of voice recognition software also provides for structured data capture
•Some EHR users prefer to copy and paste text from existing documents in order to speed up the documentation process
•Allowing this practice should be assessed carefully
•Similar to documentation in paper-based records, individuals who document in the EHR must be held accountable for their entries
•And overuse of disk space, from redundant copied information, can affect overall system response time
2. Inability to identify the author or what they thought
3. Inability to identify when the documentation was created
4. Inability to accurately support or defend E/M codes for professional or technical billing notes
5. Propagation of false information
6. Internally inconsistent progress notes
•With digital dictation, the physician dictates a medical report and the transcriptionist transcribes the dictation into a structured medical report
•The transcribed reports are electronically transmitted to the EHR
•The EDMS attaches an auto-signature deficiency and the transcribed report is then electronically routed to a physician work queue for signature.
•With voice recognition technology the computer software captures the dictation and converts the dictation to text
•Backend voice recognition software or voice recognition at the point of transcription is most commonly used for routine transcription of reports
•As the practice of medical transcription evolves and voice recognition software is utilized, emphasis is placed on medical language editing, data quality control, and text/document management
•The implementation of quality and productivity standards reduces turnaround time and improves the quality of information for workflow processes and regional health data exchange
•These processes are expanded in a fully electronic health record system. Figure 8.13 (p. 425) provides a comparison of these processes for the paper-based, hybrid, and electronic systems.
•For example, e-mail and voice mail records and audio and video data could be part of an EHR
•Consequently, policies and procedures should be in place for the management of all electronic information that is generated about patients in healthcare organizations, regardless of the record type and medium (AHIMA Workgroup on Electronic Health Records Management 2004)
•Often e-mail is used to communicate patient-specific information
•The organization should have in place policies and procedures that address the creation, storage, and maintenance of e-mail messages. •When patient-identifying information is communicated via e-mail, an e-mail management system should be used for inclusion of the data in the electronic health record
•An e-mail management system should consist of a centralized archive capable of enforcing archiving policies
•The e-mail management system should also allow e-mails to be classified by type (that is, patient e-mail) and apply rules for archiving, retention, and integration of e-mails into the electronic health record
•The management system can also be set up to automatically encrypt patient e-mails to provide a level of security
•In paper-based systems this is usually handled by transcribed notes placed into the medical record
•In an EHR environment, voice mail messages and telephone conversations should be documented
•The messages should include provider and patient identification, date and time of actual conversation or message, and the date and time of entry into the EHR. Each of these messages should also be indexed so that they can be searched, retrieved, routed, or purged
•In paper-based systems, the disposition of hardcopy materials is handled according to the organization’s written policies and procedures
•Frequently the material is incorporated into the medical record
•In fully electronic systems hardcopy materials are scanned into the EHR and diagnostic images, film, and CDs become part of the EHR
•The goal of the electronic health record system is to enable retrieval of information to assist healthcare professionals in providing quality patient care and reporting patient outcomes. •The higher degree of structure in the data entered into the EHR provides for the retrieval of meaningful data and ease of manipulation of that data.
•Data mining software is one of a number of analytical tools for analyzing large amounts of data
•It allows users to analyze data from many different dimensions, categorize it, and summarize the relationships identified. •Technically, data mining is the process of finding correlations or patterns among dozens of fields in large relational databases
•This advantage also has the potential for abuse and security risks
•Therefore, organizations must have in place appropriate security access control measures to ensure the safety of data. Chapter 15 provides a full discussion of the methods summarized below
•There are three different types of information that can be used for authentication: something you know, something you have, or something you are
•The most common method of authentication is the use of usernames and passwords
•As discussed earlier, access control is strengthened by the use of “strong” passwords that include numbers and upper- and lowercase letters and that are not easily identifiable names or numbers.
•Biometrics are individual specific identifiers such as fingerprints, retinal scans, and voice recognition that uniquely identifies the person. •Biometric identifiers are sometimes found on desktop computers, laptops, and other access devices
•It is also a set of actions that gives permission to an individual to perform specific functions such as read, write, or execute tasks
•Authorization to use specific applications (that is, order entry, coding, and registration) and specific data would be different among individuals in an organization
•For example, employees in the admitting and registration department would not be given the same authorization to use computers, programs, and data as nursing care employees
•For example, authorization may be based on not only the individual’s identity but also the individual’s role (called role-based authorization), physical location of the resource (that is, access to only certain computers), and time of day
•An example of a nonrepudiation measure in the electronic environment is the use of electronic signatures.
•The use of repudiation reduces the likelihood that an individual can deny making an entry or the timing of an entry
•The healthcare facility must have written policies that specify who, when, and how amendments, corrections, and deletions may be made to a health record
•In the electronic health record the same premise applies to making changes to a health record as it does to a paper-based record
•The HIM professional must track changes to the health record and assure appropriate follow-up in any source systems or other data repositories
•Source systems refer to other computer systems that feed information into the EHR, which would also need to be corrected according to policy when corrections are made in the EHR
•The original version of the document in a corrected health record must be maintained. The version should be clearly indicated on the document. For example, reports should indicate, “final copy,” “preliminary copy,” or “final copy with corrections.”
•A health record should be locked from editing once the final signature has been applied.
•The appearance of information added to the record to amend or correct it should be different than the original entry (that is, it may be a different color, italic, or bolded)
•The healthcare facility must consider state and federal regulations, statutes of limitation, research and educational needs, and patient care needs
•Many healthcare facilities maintain health records indefinitely or for a period that exceeds the statutes of limitations.
•For example, retention requirements or guidelines are typically longer for the records of minors than adult health records
•Regardless of the media used to store records, at some point the healthcare facility will need to address when and how health records will be purged and/or destroyed.
•With selective destruction, the healthcare facility may choose to purge specific information from the health record after the retention period has expired
•For example, the facility may have a policy where nursing graphic reports may be purged from the system, but physician documentation is maintained.
•The EHR equipment may have patient health information stored on it
•Policies must specifically address how health information will be removed from servers, workstations, laptop computers, and other storage media once this hardware will no longer be used for the EHR
•The removal of information from computer equipment requires more than simply deleting files
•The healthcare facility must run utility software to remove data or neutralize the data by applying magnetic erasers
•If these methods of destroying the data are not possible, the hard drive must be removed from the computer and physically destroyed. •Compact disks used for storing data may be destroyed by shredding or pulverizing and then disposal
•In the electronic environment, managing data input through good design of end-user interfaces increases the probability of quality data
•Paper documents are scanned and imaged
•Other computer systems are interfaced with the EHR (for example, laboratory results, radiology)
•Transcribed reports are electronically transmitted to the EHR
•Specifically, these features include drop-down menus, built in data values, and checkboxes •Although these features provide for consistent entry of data for routine data, they are limited in allowing the practitioner to document complex cases
•Dictation templates may be utilized to structure or prompt the physician for needed documentation, thus improving the quality of dictated reports
•Additionally, illegibility is also a quality issue when scanned images are used in the EHR •Therefore, the decision as to how much structured data may be required and when to allow unstructured data should be collaboratively decided by all stakeholders
•Most EHRs generate error reports or utilize error queues when there are mismatches between the EHR and the other computer systems that feed information into the EHR •When errors are identified, there must be a process in place for correction
•Similar to good forms design in the paper-based environment, well-designed EHR screens will provide ease of use, which in turn helps to provide quality data
•Clear labeling of buttons and data fields
•Limiting the use of abbreviations on buttons and data fields
•Consistent location on the screen of navigation buttons
•Built-in alerts to notify the user of possible errors
•Availability of references at the appropriate data field
•Prompt for more information where appropriate
•Checks for warning signs or errors
2. Input design
3. Data validation
4. Output design
•Use neutral colors and limit highlighting, flashing, and so forth to reduce eye fatigue.
•Limit choices and label commands.
•Provide “undo” buttons to make mistakes easy to override
•Use consistent grammar and terminology.
•Provide a confirmation message for any critical function (such as deleting a file)
•Sequence data input to follow workflow.
•Provide a title for each screen.
•Minimize keystrokes by using pop-up menus
•Use text boxes to enter text
•Use a selection box to allow the user to select a value from a predefined list:
—Check boxes (used for multiple selections)
—Radio buttons (used for single selections)
—On-screen list boxes
•Drop-down list boxes
•Perform a format check to ensure that data are the right type (numeric, alphabetic, and so on).
•Perform a range check to ensure that numeric data are in the correct range.
•Perform a consistency check to ensure that combinations of data are correct.
•Perform a database check to compare data against a database or file to ensure data are correct as entered
•Combine data into a single organized menu to eliminate layers of screens.
•For example, quality patient care is enhanced when there are built-in alerts that check for possible medication interactions and allergy information when medication orders are documented
•The availability of references allows the physician to easily look up information, without having to rely on memory in prescribing medications or considering a course of treatment
1. Version control of documents in the EHR requires:
2. Which of the following is a risk of copying and pasting?
3. When records from other facilities are used in clinical decision making, how is this documented in the EHR?
4. Which term verifies claim of identity?
5. How are amendments handled in the EHR?
Instructions: Indicate whether the following statements are true or false (T or F).
7. __F__ Data validation includes an undo button.
8. _T___ Policies should address how the patient information will be removed from computers at the end of their useful life.
9. __T__ Data quality begins at the point of creation.
10. __F__ Authorization is identifying a patient through the use of a user name
•The dictation is stored in either tape or disk format in the dictation system
•Medical transcriptionists retrieve the dictated reports and type them using word-processing systems
•The final typed report can be printed in paper format or stored electronically in an EHR
•In other cases, the entire medical transcription function has been outsourced (contracted out to a vendor)
•In many instances, outsourcing part or all of the transcription function can provide substantial benefits, including cost reductions and relief from staffing issues that sometimes result in transcription delays
•More recently, large in-house transcription areas and outsourcing agencies have begun using speech recognition technology to transcribe recorded dictation
•Speech recognition technology may be applied on the front end (at the point of dictation) or back end (after dictation has taken place)
•It enables the dictator’s digitized voice recording to be processed through a computer that converts it into text
•Templates or standardized documents can be used to reduce the number of errors
•The number of errors found is noted, and an error or accuracy rate is determined and compared against an established standard
2. Transcription turnaround time also can also be monitored to determine whether reports are being transcribed within the expected time frame set in a standard
•Most dictation/transcription computer management systems track the date and time reports are dictated and transcribed
•A report indicating dictation and transcription time and date can be used to determine turnaround time
•For example, release of information (ROI) may take the form of a patient’s request to mail copies of his or her records to a healthcare provider
•Figure 8.14 is an example of the computer screens used for entering ROI data
•Certain types of information such as substance-abuse treatment records, behavioral records, and HIV records require specific components be included in the authorization form per state (varies per state) and federal regulations
•If the authorization is determined to be invalid, the request is returned to the requester with an explanation as to why the request has been returned
•If the request is valid, the HIM professional proceeds to the next step
•Verification is done by comparing the information on the authorization with information in the master patient index
•The patient’s name, date of birth, Social Security number, address, and phone number are used to verify the identity of the patient whose record is requested
•The patient’s signature in the health record is compared with the patient’s signature on the authorization for release of information form
•If the authorization is invalid, the problem with the authorization is noted in the computer and the request is returned to the sender
•To comply with HIPAA standards, a healthcare facility must maintain a record that accounts for all disclosures from the health record
•(A subpoena duces tecum is a judicial request for certain information or evidence. Refer to chapter 14 for further information on subpoenas.)
•In this instance, the HIM department verifies that the subpoena is valid and that the requested information can be released to the court in compliance with state or federal law or regulations
•In such instances, a representative from the HIM department may appear in person in court or at a deposition and give sworn testimony as to the health record’s authenticity
•As a result, some HIM departments outsource this function to companies that specialize in release of medical information
•Even though it has outsourced the function, the HIM department is ultimately responsible for ensuring that proper practices are followed and that all laws and regulations are adhered to
•Standards for turnaround time for requests are established by the department
•With standards for turnaround times established, the average turnaround times for release of information may be tracked and delays in responding to requests for information addressed
•The turnaround time for the ROI function is monitored
•The date a request is received and the date the record copies are sent are entered into a computer database
•This information can be used to generate a report that will determine whether the records are being sent in a timely manner
•The accuracy of the ROI function can be monitored by checking a sample of authorization forms that have been sent or that are ready to be sent to verify the validity of the authorization and to ensure compliance with federal and state regulations
•The error rate or accuracy rate can be determined and compared against a set standard
•Productivity standards must be established in order to meet the expected turnaround time for the various types of requests
•”While productivity information may be collected manually, electronic systems offer more tools for data manipulation and can provide individual production statistics, departmental request volumes, and information regarding request turnaround times
•Timely fulfillment of requests that ensure continuity of care aligns with the overall mission of most healthcare organizations
•Thus these types of requests frequently take precedence over other categories of requestors •Monitoring the volume of backlog requests with the available resources and making appropriate staffing adjustments ensures the patient’s needs are being met” (Bock et al. 2008).
•When the volume of requests reaches beyond the workload capacity of staff meeting productivity and quality standards, the facility may decide to contract with a release of information service to process the backlog
•The legal health record refers to the health record that is maintained as the business record and is the health record that may be disclosed to authorized uses and for evidentiary purposes
•Healthcare facilities must have a policy that clearly identifies the legal health record
•Many of the EHR quality management components that assure the integrity of the data contained with the health record are key to defining the health record, including version control, authentication, lockdown procedures, and amendment and correction policies. Chapter 14 provides additional discussion about the legal health record
Departments Affected: HIM, Information Systems, Legal Services, [any additional departments affected]
Purpose: This policy identifies the health record of [organization] for business and legal purposes and to ensure that the integrity of the health record is maintained so that it can support business and legal needs.
Scope: This policy applies to all uses and disclosures of the health record for administrative, business, or evidentiary purposes. It encompasses records that may be kept in a variety of media including, but not limited to, electronic, paper, digital images, video, and audio. It excludes those health records not normally made and kept in the regular course of the business of [organization]
It is the responsibility of [the health records manager or other designated position] to:
•Work in conjunction with information services, legal services, and [other stakeholders] to create and maintain a matrix or other document that tracks the source, location, and media of each component of the health record. [Reference an addendum or other source where the health record information is found.]
•Identify any content that may be used in decision making and care of the patient that may be external to the organization (outside records and reports, PHRs, e-mail, etc.) that is not included as part of the legal record because it was not made or kept in the regular course of business
•Develop, coordinate, and administer a plan that manages all information content, regardless of location or form that comprises the legal health record of [organization]
•Develop, coordinate, and administer the process of disclosure of health information.
•Devise and administer a health record retention schedule that complies with applicable regulatory and business needs
Policy: It is the policy of [organization] to create and maintain health records that, in addition to their primary intended purpose of clinical and patient care use, will also serve the business and legal needs of [organization].
It is the policy of [organization] to maintain health records that will not be compromised and will support the business and legal needs of [organization].
•Ensure appropriate access to information systems containing components of the health record
•Execute the archiving and retention schedule pursuant to the established retention schedule.
[Additional responsibilities for other individuals or departments]
•The following disclosures must be accounted for (Stuard 2003):
-Government mandated reporting
-Disclosures by business associates that are not for treatment, payment, and healthcare operations
The date, name of person receiving the information, the address of the recipient, a description of the PHI disclosed, and a statement of the purpose of the disclosure (Stuard 2003)
•Examples of departments that are involved with disclosures that fall under the realms of the HIPAA accounting of disclosures regulations might be cancer and trauma registries, institutional review boards, social work departments, and so forth
•The enactment of the American Recovery and Reinvestment Act (ARRA) changes HIPAA requirements. Additional information about HIPAA and reporting disclosures is covered in chapter 14
•Using a classification or nomenclature system such as ICD-9-CM and/or CPT, clinical coding is a method for categorizing diagnoses and procedures. (Adoption of a new coding system called ICD-10-CM and ICD-10-PCS is planned to replace ICD-9-CM in the future.)
•This categorization is used subsequently for billing and payment purposes as well as for research and clinical quality performance reviews
•The coding professional reviews the health record and enters specific data from it into a computer database
•The process of extracting data from the health record and entering them into a computer database is called abstracting
•Figure 8.16 is an example, but not an exhaustive list, of data that may be abstracted and entered into the computer database
Transfer from a hospital
Transfer from a skill nursing facility
Transfer from another healthcare facility
Information not available
Psychiatric and alcohol
•He or she assigns ICD-9-CM (or ICD-10-CM) codes to the diagnoses and procedures and CPT codes (if applicable) to procedures documented in the record
•The coding function may be done manually by finding the correct codes in a coding book or done by using a computer program called an encoder.
•Other programs that are usually part of an encoding system are called DRG and APC groupers for acute care hospitals. DRG groupers are software programs that help coders determine the appropriate diagnosis-related group (DRG) assignment based on the logic of the system for hospital inpatients
•APC groupers are software programs that help coders determine the appropriate ambulatory payment classification for an outpatient encounter
•Data abstracted and the clinical code(s) assigned to a health record make it possible to create automated disease, operation, and physician indexes (discussed later in this chapter)
•Such indexes are essential in order to retrieve data or specific health records to conduct research or clinical quality performance studies
•In some acute care and long-term care facilities, the coding of diagnoses, procedures, and services occurs during the patient’s hospital stay
•In this method, the HIM professional goes to the nursing unit daily or periodically reviews the health record and assigns appropriate diagnosis, procedural, and service codes
•In the retrospective process, the health record is coded after patient discharge
•Coding usually occurs after the health record has been assembled and analyzed for completeness
•Criteria such as correct code assignment, missing codes, extra codes, and sequencing of codes can be established
•Any errors found should be noted, and an error or accuracy rate can be calculated to determine whether the quality standard is being met
•Major functions of revenue cycle management include: admitting/access management, case management, charge capture, HIM, patient financial services/business office, finance, compliance, and information technology (Amatayakul 2005)
•Therefore, the HIM department often manages these functions.
•Some HIM research sections are responsible for identifying candidate health records for research projects that clinicians are conducting
•An example might be that of a physician doing a study on patients diagnosed with hypertension and diabetes who are being given a specific type of medication
•In this case, the research section would use disease and procedure indexes to identify and retrieve the appropriate health records
•In some cases, the HIM research professionals might not only identify and retrieve the health records, but also actually review the selected records and abstract or collect data from them for the physician researchers.
•This is particularly the case with daily hospital census reports and percentage of occupancy •However, data entry and other errors often produce incorrect results, so it is still usually the function of the HIM department to verify the accuracy of many of the statistics calculated about institutional operations
•An index is a guide that serves as a pointer or indicator to locate something
•For example, the index at the back of this book lists key terms
•The page number(s) by each term indicates where in the book the reader can find information about that particular term
•Following is a brief overview of indexes and registries
•Patient’s health record number
•Patient’s gender, age, and race
•Attending physician’s code or name
•The hospital service
•The end result of hospitalization
•Dates of encounter (including admission and discharge for inpatients)
•For example, if the clinical quality committee wanted to see the health records for all male patients who had been diagnosed with myocardial infarction, were 50 years old or less, had been treated in the past 6 months, and had been discharged alive, the records could be easily identified and subsequently retrieved using the information in the index.
•Ad hoc reporting capabilities enable the user to select the field items he or she wants in the reports
•Standard reports are preexisting reports that have been programmed into the computer to include predefined data fields.
•In other facilities, the data may be entered during a separate function of abstracting data from the health record and entering them into the computer system
•In some cases, pertinent demographic patient information is exchanged from the automated R-ADT system and passed to the coding system •This type of data exchange helps to reduce work and data-entry redundancy and to increase data integrity and consistency
•Usually, several entries (such as encounters) can be made on one card
•There are various methods for filing disease and operation index cards
•One common method is to enter encounters sequentially by date of discharge starting at the beginning of each year
•Each card is then numbered sequentially beginning with the numeral one and filed by year
•As with any manual system, opportunities abound for data-entry error
•Cross-indexing of diseases and operations is impossible without an enormous amount of data redundancy, and retrieval is very time-consuming
•Often the information gathered for disease and operation indexes is sufficient for the physician index
•Essentially, the data required in such an index include the physician’s name or code; the health record number, diagnosis, operations, and disposition of the patients the physician treated; the dates of the patient’s admission and discharge; and the patient’s gender and age
•In addition, certain other patient demographic information may be useful.
•A more complete discussion of registries is provided in chapter 9
•Cancer registries use information from patient records to collect data for the study and treatment of cancer
•Likewise, trauma registries use information from the patient record to collect data for the study and treatment of trauma patients
•Both registries maintain large computer databases to store patient data
•A birth certificate must be completed for each newborn before the infant is discharged from the hospital
•Information is gathered from the mother’s and baby’s medical record for completion of the birth certificate
•Chapter 10 discusses birth certificate requirements and functions in additional detail
•As discussed earlier in the section on the MPI, typically, the first point of data collection in any healthcare organization is patient registration. •During the registration process, the patient provides the registration or admitting clerk with personal information
•The patient’s information is needed for the identification, treatment, and payment of healthcare services
•For example, the patient provides demographic information such as name, address, telephone number, and emergency contact information
•He or she also provides information about how payment should be handled (for example, insurance company name and insurance group number)
•Provisional diagnosis, and
•Planned treatment, is provided by the patient’s attending physician and integrated into the registration data collection and processing
•For a laboratory or radiology referral, an order for a test or treatment must be accompanied by a tentative diagnosis or a reason for the order. •The patient registration function essentially begins the process of documenting the patient’s care and treatment
•Additionally, it is the area where the health record number is assigned
•The accuracy of the information entered into the computer by the patient registration area has a significant impact on the HIM department, patient care areas, and billing department
•When data are recorded or obtained incorrectly at the start of the process, the errors follow the data throughout their use in the healthcare organization’s business and patient care processes
•For example, an error made in entering a patient’s health insurance number in the computer system will likely cause serious problems for the billing office
•An error made in recording a patient’s provisional diagnosis may have adverse effects on the delivery of patient care
•An error in assigning a new health record number to a patient who has previously been a patient at the facility and already has a number can cause filing and MPI problems if a unit numbering system is used
•As explained earlier in the section about the MPI, two numbers assigned to a single patient are often referred to as “duplicate” numbers
•Thus, the importance of getting information correct the first time and at the point where it is initially collected, entered, or recorded cannot be overstated
•Figure 8.18 shows the various areas where patient registration can occur in a large healthcare organization
•In some organizations, responsibility for patient registration or admitting falls to the director of HIM services
•In others, the admitting department reports to nursing or some other unit or is a separate department
•However, when the patient comes to the emergency department for diagnosis or treatment, registration can occur in that department
•Still another scenario is that the patient is being seen for the first time in one of the healthcare facility’s clinics
•In this case, patient registration occurs in the clinic office
•Most acute care facilities now process all patient registration data using computer systems
•Although patients may complete a paper form, the registration clerk usually enters their information into a computer system
•In a smaller healthcare delivery unit such as a physician’s office, however, registration data may still be collected and stored in a paper file
•The HIM department assigns clinical codes and abstracts information from the patient’s health record that is required on the patient’s bill •Therefore, the patient’s bill cannot be submitted for payment until the HIM department enters the required health record information into the computer
•In many facilities, a report is generated weekly that identifies patient accounts that have not been billed because of missing ICD-9-CM codes and/or CPT codes
•It is HIM personnel who locate the records to determine why there has been a delay in coding and initiate completion of the coding process so the bill can be submitted to the party responsible for payment of services
•All patient care departments document the services they provide to patients in the health record
•Therefore, they are contributors to health record content
•When the patient is discharged from the hospital or leaves a clinic, the HIM department retrieves records from previous admissions or visits in addition to records of the patient’s recent admission/visit
•The health record then is routed to the record-processing area of the HIM department
•The HIM professionals are the experts in health record content and provide knowledge of regulations to assure that records comply with federal, state, and accreditation standards
•The HIM professional also provides input to the efficient and effective health record information flow
•The HIM professional also understands privacy standards and protects health record content from unauthorized access
•The HIM professional is the resource person for the health record data needs of the facility
•The IS professional assures that the infrastructure needed to support the computer needs is in place
•The IS professional is responsible to assure that interfaces between computer systems work properly, system backups are completed in order to protect from the loss of data, software is installed and working properly, and computer equipment is maintained
•The HIM professional is the administrative EHR expert and the IS professional is the technical expert for a successful EHR
•In a support capacity, the HIT may be responsible for taking minutes of the committee meeting, distributing the meeting agenda to committee members, and providing statistics or other required information
•As a liaison, the HIT’s expertise is frequently required
•For example, serving on the organization’s health record committee, the HIT may be asked to clarify policies, procedures, and accreditation requirements
•In fulfilling this role, the HIM department has worked with appropriate medical staff committees, clinical departments, and administration
•HIM performs many of the same functions when working with an EHR
•The department helps ensure that record content and authentication (signatures) in the EHR meet accreditation and licensing requirements and also participates in user-interface design for computerized data input
•Virtual HIM refers to the HIM functions traditionally performed within the walls of the healthcare facility being done remotely
•For the past several decades, many medical transcriptionists have worked from home •Digital dictation technology has allowed the medical transcriptionist to access dictation via phone lines or computer WAV files
•With the implementation of hybrid and electronic health record some facilities have permitted medical coders to work from home
•As paper-based functions are eliminated from the HIM workflow, it becomes possible to perform HIM functions from remote locations
•Additionally, virtual HIM also provides opportunities for HIM functions to be outsourced.
•The Joint Commission is a not-for-profit organization that offers an accreditation program for hospitals and other healthcare organizations based on pre-established accreditation standards (JCAHO 2005).
•National Committee for Quality Assurance (NCQA)
•American Accreditation Health Care Commission/Utilization Review Accreditation Commission (AAHCC/URAC)
•American Osteopathic Association (AOA)
•Commission on Accreditation of Rehabilitation Facilities (CARF)
•Health Accreditation Program of the National League of Nursing
•College of American Pathologists (CAP)
•American Association of Blood Banks (AABB)
•American College of Surgeons (ACS)
•Accreditation Association for Ambulatory Health Care (AAAHC)
•American Medical Accreditation Program (AMAP)
•As part of the accreditation process, the healthcare facility undergoes an on-site evaluation by a team of Joint Commission surveyors
•It is during the survey that TJC evaluates the quality of care provided to patients, the systems in place for ensuring caregiver and medical staff competence, and the performance of important patient functions
•In the past, the on-site survey was a scheduled event.
•The PPR is a hospital’s review of standards, compliance with standards, action plans implemented to address noncompliance with standards, and measures to follow up on the success of the action plans
•TJC survey, the PPR, and the PFP are used to indicate that the healthcare facility is in compliance with Joint Commission standards
•This is referred to as deemed status
•Medicare randomly selects hospitals recently surveyed by TJC and conducts another survey to validate TJC survey results
•The HIM department director should establish a mechanism that targets specific regulatory or standards groups and monitors for compliance with these standards
•New standards and changes to regulations must be monitored and HIM functions revised if necessary
•Because the HIM department’s functions include review and analysis of the health record, several processes are typically in place to monitor the healthcare facility’s compliance with Joint Commission standards
•Many facilities determine the number of delinquent records each month and notify their medical staff members of their incomplete and delinquent records
•The HIM professional determines the quarterly medical record delinquency rate for the facility and determines whether the hospital is in compliance with Joint Commission standards
•If the hospital is not in compliance with TJC, the medical records committee, administration, and other appropriate parties are notified and corrective is action taken
•There may be various consequences for physicians when they have not completed delinquent charts within a specified period of time
—Monitoring timely completion of medical reports: Other Joint Commission standards specify time frames within which various medical reports (history and physicals, operative reports, autopsy reports, and so on) must be completed
•The HIM department’s transcription area may monitor compliance in this area
•The transcriptionist can compare the date a report was dictated against the date of service or admission to determine whether the report has been completed within the time frame specified by the standards.
—Monitoring health record completion: The quantitative analysis function of the HIM department monitors whether health record documents have been authenticated
•Unauthenticated parts of the health record are identified for completion by either handwritten or electronic signature
•If the physician does not complete the record within a timely manner, the record is counted in the delinquent record rate.
Transcriptionists can assist with monitoring the use of abbreviations, acronyms, and symbols as they transcribe dictation
•Clinical coding personnel also can identify the use of unauthorized abbreviations, acronyms, and symbols as they abstract information from health records
•This is an example of the HIM professional’s role in monitoring hospital compliance with TJC’s standard on abbreviation usage in the health record
The HIM department’s daily ROI activities can help ensure and monitor access to patient-specific information after discharge
•HIM personnel are knowledgeable in the laws and regulations governing the release of patient information
•Thus, the department’s ROI function is instrumental in monitoring compliance with Joint Commission standards regarding access to protected health information.
•The HIM professional must consult the Comprehensive Accreditation Manual for Hospitals published by TJC for a complete listing of standards and elements of performance
•TJC also publishes accreditation manuals for specialty areas, such as long-term care and behavioral healthcare facilities
•In addition to monitoring performed as part of daily HIM functions, health record reviews are often done periodically to ensure facility compliance with other standards
•The health records review process is a multidisciplinary process coordinated by the HIM department
•Chapter 18 also provides a detailed discussion on management and supervisory issues
•Figure 8.20 is an example of a policy that provides guidance for the assignment of overtime within the HIM department
•Every policy must be dated, and if there has been a revision, the date of the revision also should appear on the policy
•The format of a policy statement varies from organization to organization.
Scope: University Hospital’s terminals
Standard: Proper physical and software control mechanisms shall be in place to control access to and use of devices connected to University Hospital’s computer systems
1. Hardware Terminal Locking: In areas that are not physically secured, terminals should be equipped with locking devices to prevent their use during unattended periods. The locks should be installed in addition to programmed restrictions, such as automatic disconnect after a given period of inactivity
•Essentially, they are specific instructions to help employees carry out a function or activity •Procedures provide step-by-step instructions on how to complete a specific task
•Written procedures are beneficial as a training tool for new employees
•They also are beneficial for providing staff with a consistent method of completing tasks
•This procedure also demonstrates the interrelationship of the HIM department with the nursing units and the intra-relationship among the different functions of the HIM department
The following list provides an example of the types of policies and procedures that may be included in a manual for health information services. The titles and content of the policies and procedures may vary by facility or corporation. Some of the policies and procedures are listed more than once for cross-referencing purposes
Access to Automated/Computerized Records
Access to Records (Release of Information) by Resident and by Staff
Facility Procedures—Establishing/Closing the Record
Preparing the Medical Record
Preparing the Master Patient Index Card
Readmission—Continued Use of Previous Record
Amendment of Clinical Records
Audit and Monitoring System
Specialized Audits (examples)
Change in Condition
Nursing Assistant Flow Sheet
Psychotropic Drug Documentation
Chart Removal and Chart Locator Log
Clinical Records, Definition of Records, and Record Service
Access to Records
Automation of Records (See also Computerization)
Change in Ownership
Coding from home
Completion and Correction of Records
Definition of the legal record
Ownership of Records
Permanent and Capable of Being Photocopied
Storage of Records
Willful Falsification/Willful Omission
Closing the Record
Coding and Indexing, Disease Index
Committee Minutes Guidelines
Computerization and Security of Automated Data/Records
Confidentiality (See Release of Information)
Consulting Services for Clinical Records and Plan of Service
Content, Record (the list provided is not all-inclusive and should be tailored to the facility/corporation)
Transfer Form/Discharge Plan of Care
Discharge against Medical Advice
Physician Consultant Reports
Physician Orders/Telephone Orders
Physician Services Guidelines and Progress Notes
Physician History and Physical Exam
Interdisciplinary Progress Notes
Copying/Release of Records—General
Correcting Clinical Records
Definition of Clinical Records/Health Information Service
Delinquent Physician Visit
Denial Letters, Medicare
Destruction of Records, Log
Disaster Planning for Health Information
Assembly of Discharge Record
Chart Order on Discharge
Completing and Filing Master Patient Index Card
Discharge Chart Audit
Notification of Deficiencies
Incomplete Record File
Closure of Incomplete Clinical Record
Preparation of the record, imaging of records, quality review
Emergency Disaster Evacuation
Falsification of Records, Willful
Filing Order, Discharge (Chart Order)
Filing Order, In-house (Chart Order)
Filing System, Unit Record
Forms, Release of Information
Guide to Location of Items in the Health Information Department
Guidelines, Committee Minutes
Incomplete Record File
Disease Index and Forms for Indexing
Master Patient Index
Release of Information Index/Log
In-service Training Minutes/Record
Health Information Coordinator
Health Unit Coordinator
Other Health Information Staff (if applicable)
Master Patient Index
Certification and Recertification
Medicare Denial Procedure and Letter
Ombudsman, Review/Access to Records
Order of Filing, Discharge
Order of Filing, In-house
Organizational Chart for Health Information Department
Orientation/Training of Health Information Department
Physician Visit Schedule, Letters, and Monitoring
Physician Visits, Delinquent Visit Follow-up
Health Information Participation
QA Studies and Reporting
Readmission—Continued Use of Previous Record
Recertification or Certification (Medicare)
Reconstruction of Lost Record
Refusal of Treatment
Release of Information
Confidentiality Statement by Staff
Copying/Release of Records—General
Faxing Medical Information
Procedure for Release—Sample Letters and Authorizations
Redisclosure of Clinical Information
Resident Access to Records
Retrieval of Records (sign-out system)
Uses and disclosures of protected health information, uses and disclosures of deidentified documentation, business-associated contracts, audit trails
Witnessing Legal Documents
From Hospitals and Other Healthcare Providers
Request for Information Form
Retention of Records and Destruction after Retention Period
Example Statement for Destruction
Retrieval of Records
Security of Automated Data/Electronic Medical Records
Storage of Records
Maintaining Overflow Record
Unit Record System
•Essentially, it is a type of planning tool as well as an evaluation tool.
•An expense budget is a prediction of how much expense an organization is going to generate. The expense budget includes things such as employee salaries and supplies.
•A capital budget is a projection or plan of what the organization intends to spend on long-lived assets such as a piece of equipment.
•A cash budget is the anticipated flow of cash into and out of the organization
•In fact, the budgeting process may begin several months before the budget period begins
•For example, department directors may be asked to submit their estimates regarding revenue and expenses to upper management in July for a budget period that actually begins the following January
•After upper management receives the department director’s budget projections, the director usually has to explain and justify them at a hearing before a budget committee or senior management
•At or after the budget hearing, the department director is given feedback, negotiations are undertaken, and adjustments are made. Senior management makes the final budget allocations
•These types of requirements are based on considerations such as work volume, staffing needs, changes in departmental functions, and so on
•For example, when senior managers predict that the volume of inpatients is going to increase in the next year, the increase may affect HIM department resources and staffing
•The increased volume of patients might be reflected in the need to purchase more file folders. There will be increased dictation and thus transcription of medical reports
•Additionally, there will be more health records to store and file. Such increases will have a direct impact on the HIM department’s budget
•The variance report answers the question about how far away actual expenses and revenues are from the targeted budget amounts
•Budget variance reports are usually provided every month to department managers so that they can keep track of actual-versus-projected revenue and expenses and take appropriate action to try to stay within the projected budget
•This activity falls within the scope of supervision of HIM functions
•To conduct employee appraisals, the HIM department must have policies, procedures, job descriptions, and work standards in place. •Chapters 11 and 18 discuss performance assessment concepts and practices.
•Expansion of network capabilities
•Emergence of new technologies such as EHRs, natural language processing, and computer-assisted coding
•Move toward ICD-10-CM and ICD-10-PCS
•Societal and regulatory requirements for information privacy and security
•Greater demand and accountability for improved healthcare quality and patient safety that can be facilitated through the use of information technology
•Increased consumer knowledge of personal healthcare decisions and increased focus on personal health records
•ARRA provides financial assistance and incentives necessary for the transition to electronic health records
•The Office of the National Coordinator for Health Information Technology (ONC), a federal entity located within the Office of the Secretary for the U.S. Department of Health and Human Services (HHS), is responsible for the coordination of the national initiative that all providers adopt an EHR by 2014
•The ONC was established in 2004 and in February 2009 the ARRA expanded the role of this office to further support the EHR initiative through funding and the establishment of standards (ONC 2009)
•As part of the information age, an explosion of information technology (IT) is transforming the workplace
•Many healthcare facilities have either implemented an EHR or are in the transitional stages of implementing one; however, many of the EHRs today use a large amount of imaged documents
•As EHRs evolve, the expanded use of database technology and direct data input will be necessary to meet industry standards and demands for information
•Implementation of the revised or new coding systems will require that clinical coders be retrained to use them
•Moreover, it will require software vendors to provide new products, which could expand opportunities for HIM professionals
•Evidence suggests that this phenomenon is already occurring as HIM professionals move into roles in data security, organizational compliance, health data analysis, medical staff services, and so on.
•Vision 2016 also discusses the need to provide a pathway for advanced practice role for HIM professionals through the development of graduate degree programs.
•The position includes working with the chief information executive and system users to advance systems, methods, and application support and to improve data quality, access, privacy, security, and usability
•The clinical data specialist would perform data management functions in a variety of application areas, including clinical coding, outcomes management, specialty registries, and research databases
•The patient information coordinator would perform new service roles that help consumers manage their personal health information, including personal health history management, ROI, managed care services, and information resources
•The data quality manager would perform functions involving formalized continuous quality improvement for data integrity throughout the enterprise, beginning with data dictionary and policy development and including quality monitoring and audits
•The data resource administrator would be responsible for the next generation of records and data management using media such as the CPR, the data repository, and electronic warehousing for meeting current and future care needs across the continuum, providing access to the needed information, and ensuring long-term integrity and access
•The research and decision support analyst would support senior management with information for decision making and strategy development using a variety of analytical tools and databases
•The position would work with product and policy organizations on high-level analysis projects such as clinical trials and outcomes research
•The security officer would manage the security of all electronically maintained information, including the promulgation of security requirements, policies and privilege systems, and performance audits
•Yet, with their unique mixture of clinical and information skills, HITs are poised for success
Implementation support specialists
•Technical/software support staff
•Employers also will demand that employees continually add to their skill sets to meet changing needs
•That is why another fundamental principle of AHIMA is the need for lifelong learning
•HIM professionals must be committed to ongoing education and professional development
1. If one needed to know the number of C-sections performed by a specific obstetrician, which of the following indices would be used to identify the cases?
2. The computer system that may serve as the MPI function is the:
3. A chronological listing of data is called a/an:
4. What department within the hospital uses the information abstracted and coded by the HIM department to send for payment from third-party payers?
5. The function within the HIM department responsible for listening to dictated reports and typing them into a medical report format is called:
6. Reviewing requests for health record copies and determining if they are valid is part of what function within the HIM department?
7. Where does the health record begin?
8. One of the most sought after accreditation distinction by healthcare facilities is offered by the:
9. Statements that describe general guidelines that direct behavior or direct or constrain decision making are called:
10. Step-by-step instructions on how to complete a specific task are called:
11. The departmental budget is both an evaluation tool and what type of tool?
12. Employee salaries are part of what type of budget?
13. The purchase of an EHR system would be planned for in what type of budget?
14. Assigning ICD-9-CM and CPT codes to the diagnoses and procedures documented in the medical record is called:
15. Which of the following is an example of how the HIM professional interacts with the medical staff?