VENITA JONESHIT 271 CAPSTONEDEVRY UNIVERSITY

SPRING B 2011

3716 Highway 39 NorthMeridian, MS 39301

601-482-7164

Kristy Certain, NHA

Previously known as Riley Nursing Center

Long-Term Care & Rehabilitation Services

80 Licensed Beds – Currently 74 Patients

Medicare and Medicaid Eligible

For-Profit Corporation by LaVie Care Centers Scott Bartes, CEO

LaVie’s Core Values

Team

Compassion

Quality Commitment

Service Excellence

Fun

Healthcare Services

24-Hour Skilled Nursing Care

Comprehensive Rehabilitation Services

Nutritional ServicesIV TherapyPharmacy & Laboratory

ServicesRadiology ServicesDischarge Planning

ServicesQMRP ServicesOffsite Medical

Services

Specialized Wound Care Program Post-Surgical Wound

Care Wounds Resulting from

Diabetes Wounds Due to Poor

Circulation Venous Stasis Ulcers Pressure Ulcers Non-healing Surgical or

Traumatic Wounds

Comprehensive Rehabilitation Services

Physical Therapy

Occupational Therapy

Speech Therapy

Discipline-Specific Treatment Programs

Patient/Family Training & Education

Discharge Planning

The Oaks Healthcare Team

Medical DirectorFour Staff Physicians/1

Nurse PractitionerDirector of NursingRegistered NursesLicensed

Practical/Vocational Nurses

Certified Nursing Assistants

Rehabilitation Coordinator

Physical Therapists

Four Occupational Therapists

Speech TherapistsDietary Manager & 8

AidesRegistered DietitianSocial Services DirectorPsychiatric, Podiatry,

Dental & other Specialists as needed

Health Information StaffBilling & ReimbursementActivity Director & 3

AidesLaundry & Housekeeping

The Oaks Organizational Chart-Page 1

The Oaks Organizational Chart-Page 2

Offsite Services Offered to The Oaks

LaboratoryRadiology PharmacologyVarious SpecialistsDentalPsychiatric ServicesRenal Dialysis ServicesHospice Services

Electronic Health Records Systems Utilized

American Healthtech®Utilized by the majority of the staff in this facility. The main page entities includes reports, CMS, Setup, Custom, Demographics and the following resident documentation entities: basic information, clinical information, status changes, therapy, Part D Plans, billing and after hours ADT.

Resource Systems: CareTracker®Used for utilization of patient activities of daily living skills (ADLs) and vital signs.

Resources Systems: MDS Director™Used by the MDS coordinator as required for facilities receiving federal funding.

LaVie Health SystemsUtilized by nursing and various therapies in documenting information on residents.

Orientation to The Oaks/Daily Functions

I visited the facility a few days before my practicum. I met with the nursing home administrator Kristy Certain. I signed the necessary contracts and privacy notices. I was then introduced to the medical record worker Lori Yoder. She gave me a tour of the facility and introduced me to the staff. I found the environment to be warm and inviting. The 80-bed facility had a lobby, dining area, smoking area, activity area, resident dayroom, physical therapy area, two residential wings and various offices. I noticed that CareTracker ® systems were located at the two wings and in the dining area. TCO – 2,6, 7

There were also three sheds located at the back of the facility. One for medical and administrative records, another for miscellaneous records/building items and another for laundry duties. TCO -1

Collection of pink slips—physician telephone orders written by nurses. This information is inputted into the American Healthtech® EHR systems. TCO 1, 8

Month’s end duties consists of physician orders for the month is printed out, death reports are sent to Vital Records by fax, rollover orders are updated for the next month. Examples of rollover orders are Vitamin B12 shots which are fixed dosages/times and Accu-Chek® monitoring for diabetic patients. TCO 1, 4, 5

Daily meetings are held in the dining area. Representatives of different staff are present. The daily census report is read including the count for Medicare, Medicaid, Private Pay, Pending Medicaid, room changes, resident information statuses & miscellaneous hospitalizations, admissions, discharges, transfers, and deaths. Also daily activities and appointments are also discussed. Excellent communication is observed. TCO 9

Observations & Hands-On Experiences

Health information data collection are obtained from physician telephone orders, admissions/discharge/transfer information, resident charts, and medication administration records (MARs). TCO 1, 2, 8

Legal matters—Power of Attorney, a copy is put in the chart and copy in the medical record. The same goes for the advance directive. TCO 1, 7

Lab reports are queried to nurses if necessary—BMP everyday. Lab Requisitions are maintained by the medical record personnel. TCO 2, 8

Older records are located in a locked shed outside of the facility. Other facility records are also located here. An offsite records facility is also utilized.

Filing system is in alphabetical order. I assisted in filing and rearranging files in the new lateral shelf cabinets. TCO 2

I went with my preceptor almost daily to do offsite doctor rounds to collect signatures on orders and documentation on residents. Also prescriptions are picked up and faxed to the pharmacy. Copies of faxed prescriptions are filed . TCO 2,

New admissions are created by using the –chart health information program for medical charts. TCO 1, 2, 8

Observed how a face sheet and clinical information is created. Data entry of patient information is derived from admissions information (abstraction). Print three face sheets for the following: resident chart, podiatrist (comes every three weeks), and the Master Patient/Patient Index Card (stored in a large notebook) TCO 1, 2, 8

Chart creations consists of MARs-Face sheet, Diagnosis sheet, physician orders, Treatment sheets, Nursing—Diabetic Flow sheets-if applicable. TBT, CXR, H&P are also in chart. TCO 1, 2, 8

Three types of charts are created: Treatment book, MARs, and Resident Chart. TCO 1, 2, 8

Observed the creation of lab requisition for residents. TCO 1, 2, 8

Observations and Hands-On Experiences cont.

Admissions packets creation: Admissions order Immunization Record Master signature log Lift profile Full Code notice Pain Assessment sheet TB Screening and Testing

Record Physician progress notes Care plan Release of responsibility for

leave of absences/passes *Resident Information Sheet

to be used in the CareTracker® system.

TCO 1, 2, 3, 7, 8

Non-EHR sources used:ICD-9-CM for Skilled Nursing Facilities and Hospices, Volumes 1, 2, & 3 (2010)

Care Management Review is done once a week. Patient changes such as

weight, bowel movements, behavior, etc.

Care review/care plan for assessments: Diabetics/insulin Teeth Infections Hypertension Code statuses Medications

TCO 1, 4, 5, 8

Hands-On Experiences

Utilized reading physician telephone orders and deciphered medical terms. TCO 1, 2, 8

Data entry of new information on the EHR. My preceptor walked with me through the process. TCO 1, 3, 8

Sorting and filing loose papers. TCO 1

Utilized the electronic ICD-9-CM codes and NDC code programs as well. TCO 1, 2, 3, 8

Learned how to enter times/time codes for drug administration and appointments. TCO 1, 8

Input information into the CareTracker system. TCO 1, 8

Learned how to do quantitative analysis of charts by checking the charts for physician signatures and dates on doctor’s orders and flagging the charts for signatures. TCO 2

Also checked the charts to make sure the residents’ name, medical record number, physician’s name, and room number are filled in on various documentation on in the chart. TCO 2

Filed documentation in chart that is more than three months old from current date. TCO 2

Filed resident medication records in filing cabinet. TCO 2

A visit with the MDS Coordinator

The MDS Coordinator is a registered nurse

Utilizes the Resource Systems MDS Director program.

Keys in information from the resident charts and the face sheet onto the MDS program

Collects pain assessment information and makes sure they are signed

Performs data entry of CareTracker assessments

Assessment timetable Admissions, 5-day, 14-day, 30-day,

and 90-day Timetable of MDS review

5-day—pays up to 10 days 14-day—pays up to 30 days

TCO 1, 2, 4, 5, 8

Care plans are done five days after admission

MARs are also checked for medications such as insulin, behavioral medications, etc.

Protocol of Patient Assessment Assessment/MDS Decision Making Care Area Assessment (CAA) Care Plan Development Care Plan Implementation Evaluation

Resident Assessment Instrument (RAI) for Nursing Homes is utilized Three basic components

MDS v. 3.0 CAA-Care Area Assessment RAI-Utilization Guidelines

TCO 1, 2, 3, 4, 5, 8

Concerns/Conclusion

Notes of Concern Lack of staffing in medical records

department, only one medical record staff and no workspace

Location of storage shed for older records

Medical records office is too small for filing duties and chart preparation

Disaster preparedness for medical records

Interdisciplinary chart review should be implemented with other healthcare professionals

Location of policy and procedures should be easily accessible

Conclusion The practicum experience began

with meeting with the nursing home administrator and the only medical records staff. I observed the various duties done in the health information department. I was able to gain experience working on the EHR and utilize skills in medical terminology, health records documentation and quantitative analysis. I didn’t know that MDS and care plans are done by RNs and I had a chance to observe what they do. Attending meetings gave insight on the happenings at the facility. I also established a rapport with the various staff at the facility. I also learned what type of documentation procedures are done by other staff members. I enjoyed doing the quantitative analysis at the nursing station, which gave me a view how the nursing staff utilize the CareTracker system along with the EHRs specialized for nurses well. In conclusion, there is never a dull moment in processing health information and it involves everyone.

Final Thoughts

My final thoughts on this practicum was a memorable one. I am glad that I had finally got a chance to work in the medical records department at a skilled nursing facility. It was definitely a difference as compared to our studies which focused on the hospital and physician offices. Working with someone that was non-credentialed and less than two years of experience in health information was an eye opener but she knew how the processes went. Plus the fact the she was the only medical records staff working there. I can imagine the pressure she goes through. The filing system was a different because the preceptor was alphabetizing in reverse order—from the back to the front. When I noted this in my class discussion, I discovered that this is the way the military does their filing system. I was able to meet most of my TCOs but was disappointed that I wasn’t able to observe the processes of billing and admissions . TCO 3

I was able to get hands on experience on abstracting information to the EHRs, filing loose papers and records, and doing quantitative analysis on residents’ charts. I along with other staff from different professions as well. I felt like I was a regular employee while I was there. It felt good to be complimented that I was a hard worker and stayed on task on whatever duties was given to me. I also enjoyed interacting with my classmates during the discussions and the experiences they were going through.

Working in the health information field is no easy feat but I respect the profession to the fullest extent. I didn’t realize there is so much to the medical record and to the medical records staff. This is a challenging profession but provides the link between the patient and provider when it comes to health information documentation.