health information/ record manual health information record systems approval approval/health...
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HEALTH INFORMATION/ RECORD MANUAL
Health Information Record Systems ApprovalApproval/Health Information/Record
Management SystemsResponsibility for Records/Signature
Regulatory Documentation RequirementsCalifornia (#0030)Iowa (#0031)Kansas (#0032)Missouri (#0033)Nevada (#0034)New Mexico (#0035)Texas (#0036)
Health Information/Record Service OrganizationIntroduction – Defines the
Clinical communication tool used among health care providers;
A legal document that describes the health care services provided to the resident.
IntroductionEach resident admitted to the center will have:
A record (electronic and/or paper) initiated on admission;
Completed in accordance with state and federal regulations;
Accepted professional practices with formalized systems in place;
Maintenance of records;Records are readily accessible;Accurate both manual and electronic.
HIPAAGuidance in the Health Insurance Portability
and Accountability Act. 1996 (HIPAA) [45 C.F.R. 164.5…], Department of Health and Human Services Part 160 and 164 Breach Notification for Unsecured Protected Health Information and any subsequent HIPAA rules and applicable other State and Federal laws/regulations.Refer to Skilled HC.
OrganizationRecord Responsibility (#1015) –
See sample on following slideInterview Tool Questions (#1016) –
See sample on following slideInterview Tool Answers (#1017)Job Description Health Information Director
(#1020)Job Description Regional HI Management
Coordinator (#1025 – See Skilled HC)
Record Responsibility (Sample)
Interview Tool Questions (Sample)
Organization -2
Staff Development/Orientation/Training (#1035) – See sample on following slide
Lesson Plan & Attendance Sheet (#1036)Health Information Director Orientation Training &
Evaluation Checklist (#1037)Performance Measures / Staff Competencies /
Training Guide (#1038) – See sample on following slide
Health Information / Record Department System Skills Evaluation (#1039)
Health Information/Record System Department Report to Administrator (#1040)
Staff Development /Orientation / Training (Sample)
Performance Measures /Staff Competencies (Sample)
Clinical Record Service/General PoliciesLegal Medical Record & Related
Policies/Procedures (#2007) – Also Skilled HC Review
Definition of Record Set (#2008)General Record Policies / Documentation
Guidelines (#2010)
Clinical Record Service/General Policies -2
Resident Record Content (#2015)Admission Record/Face SheetAdvance Directive Acknowledgment / POLSTAllergiesAlternate Schedule of Physician VisitsAncillary AssessmentsBehavior Drugs/PsychotropicBowel/Bladder AssessmentCare Plan/Plan of Care Certification/RecertificationComprehensive Resident Assessment Instrument
(MDS)
Clinical Record Service/General Policies -3
Resident Record Content (#2015)…cont.Consents/RightsConservatorshipConsultation ReportsDiagnosesHistory/PhysicalIndividual Health Care InstructionInterdisciplinary Discharge SummaryInterfacility Transfer Report/SummaryLaboratory/X-Ray/Diagnostic ReportsLeave of Absence/Pass RecordLength (Height)/Weight
Clinical Record Service/General Policies -4
Resident Record Content (#2015)…cont. Licensed Nursing Notes MedicareMedication and Treatment AdministrationMinimum Data Set (MDS)MonitorsMortician’s ReceiptNotification to PhysicianNurse Practitioner – see Physician VisitsNursing Assistant NotesPharmacy ReviewPhysician Assistants – see Physician Visits
Clinical Record Service/General Policies -5
Resident Record Content (#2015)…cont. Physician Extenders – see Physician VisitsPhysician OrdersPhysician Progress NotesPhysician VisitsPhysician’s Discharge SummaryPlan of Care – see Care PlanPossessions ListPreferred Intensity of Care/No CPR/DNR RequestPsychotropic – see Behavior DrugsRehabilitative/Specialized TherapyResident Data Set
Clinical Record Service/General Policies -6
Resident Record Content (#2015)…cont. Restorative NursingRestraints-PhysicalSmokingSurrogate Decision MakerThirty-Day Notice Tuberculosis ScreeningTurningVital signsWeight
Willful Falsification / Willful OmissionWillful Falsification/Willful Omission (#2025)
Readmission/Record ProcessReadmission (#3005)
By State
Discharge ProceduresOrder of Filing/Shortened Discharge Chart
(#3501 - #3507) - By State Discharge Chart Monitor (#3520) – See
sample on following slideIncomplete Record Procedure (#3525)
Discharge Chart Monitor (Sample)
Health Information/Record TasksGuide to Location of Items in Health
Information / Record Department (#4005)Record Tasks (#4010)Monitoring Schedule (#4011) – See sample on
following slideNumber System/Filing (#4020)Unit Record (#4025)
Monitoring Schedule (Sample)
Establishing and Closing the Record, Filing, ClearanceEstablishing/Closing the Record (#4030)In-House Order of Filing (#4031 - #4037) – By
StateClearance of Records / Thinning (#4040)
Establishing and Closing the Record, Filing, Clearance -2
Retrieval of Records – Chart Locator System (#4050)
Lost Record / Reconstruction (#4055)Storage of Records / Destruction After
Retention Period (#4060)Off-Site Storage of Records (#4065)Retention of Records – General
(#4070)
Indices/Registries/Coding, OtherIndices/Registries (#5005 – Refer to Skilled
HC)Master Resident Index (#5010)Monthly Review of Physician Orders (#6005 –
Refer to Skilled HC)Delinquent Visit/Follow-Up (#6010)
Disaster Planning, Ancillary Log, Committee MinutesDisaster Planning for Health Information
(#6015 – Refer to Skilled HC)Laboratory/X-Ray Log (#6020 – Refer to
Skilled HC)Guidelines for Committee Minutes (#6025 –
Refer to Skilled HC)
Confidentiality/Security of Health Information – Refer to Skilled HC)Notice of Privacy Practices (#7001 )Reporting of Unlawful/Unauthorized Access, Use and
Disclosure of Protected Health Information (#7002)Use & Disclosure of PHI – Minimum Necessary (#7003)Resident Access to Records (#7007)Amendment/Addendum to Records (#7009)Subpoena (#7011)Ombudsman/Review of Records (#7013)Accounting/Tracking of Disclosures (#7015)Facsimile (Fax) Machines (#7017)Confidentiality/Security of Information –
Manual/Automated (#7019)Training in Privacy Regulations (#7021)
Monitors/Completion InstructionsMonitor Schedule – See #4011Monitors – with Policy/Procedure and
Instructions (alphabetized) – Section 7050Admission MonitorChange of Condition Monitor
- See sample on following slideCNA / ADL Flow Sheet MonitorGeneral Update / Clinical Record Monitor
(Pacific Region)General Update Log (Central/Midwest Regions)
Monitors/Completion Instructions -2
Monitors – with Policy/Procedure and Instructions (alphabetized) – Section 7050Medication / Treatment MonitorPressure Sore/Ulcer/Skin Conditions Monitor
COC Monitor (Sample)
Additional Monitors – with Brief Instructions - Section #7051Advance Directive/IHCI/Preferred Intensity of
Care (PIC) /Physician Orders for Life Sustaining Treatment (POLST) Monitor
Behavior Drug MonitorBowel/Bladder Training MonitorCare Plan Monitor (Future)Diabetic MonitorDialysis MonitorHospice Monitor
Additional Monitors – with Brief Instructions - Section #7051 -2
Intake/Output/Catheter Monitor (Future)Licensed Progress Note MonitorRespite Care Monitor (Future)Restrictive Device/Restraint MonitorWeight Monitor/Weekly Weight
Monitor/Weight Log - See Skilled HC
Additional Monitors – with Brief InstructionsMedication/Treatment Self Monitor (#7052 –
Future)Monitors/Completion Instructions – EHR
System (#7053 – Future)Monitors/Completion Instructions – Manual
(#7054 – Future)
Resident Assessment/Prospective Payment System/MedicareElectronic Signatures (#8020 – Refer to
Skilled HC)Medicare Log (#8025 – Refer to Skilled HC)Medicare Certification/Re-Certification (#8030
– Refer to Skilled HC)
MiscellaneousAbbreviations/Symbols (#9005 – Future)Request for Hospital Information – Sample
Letter to Acute Hospital for Records (#9010)
Hyperlinks to State Regulations – Appendix ACalifornia IowaKansasMissouriNevadaNew MexicoTexas
HIM Record Manual Questions or Corrections – Appendix BContact [email protected] and [email protected]
for any updates, changes, etc.Or fax to AHIS’ office at 714-558-1302
Questions?Rhonda L. Anderson, RHIA
PresidentAnderson Health Information Systems, Inc.
940 W. 17th Street, Suite BSanta Ana, CA 92706
Tel. 714/558-3887Mobile 714/299-0573