Presentation on theme: "Documentation for Acute Care"— Presentation transcript:
1 Documentation for Acute Care Chapter 2Functions of the Acute Care Health Record
2 IntroductionData – represents objective descriptions of processes, procedures, people, and other observable things and activitiesInformation – the result of analysis of data for a specific purpose
3 Introduction – cont’dInitially all health record information was stored in paper formatHandwritten progress notes, paper forms, photographs, graphic tracings, and typewritten reports
4 Electronic Health Record (EHR) movement Gained momentum since the implementation of HIPAAImplementation of ICD-10-CM and ICD-10-PCS will also add to the move to EHR
5 Principal Functions of the Acute Care Record Repository for the clinical documentation relevant to the care and treatment of one specific patientPatient care deliveryPatient care managementPatient care supportBilling and reimbursement
6 Functions of health record in patient care delivery A data and information collection and storage toolA service documentation toolA communication tool for the patient’s caregiversA diagnostic toolA tool for patient assessment and care planningA health record is a risk assessment toolA discharge planning tool
7 EHR performs several additional clinical functions Clinical decision supportError prevention toolEnhanced discharge planning tool
8 Functions of the health record in patient care management and support The allocation of the healthcare organization’s resourcesThe analysis of trends in the usage of patient servicesThe forecasting of future demand for servicesThe communication of information of different clinical departments
9 Patient Care Management Case mix – a method of grouping patients according to a predefined set of characteristics.Case management – the ongoing review of clinical care conducted during the patient’s hospital stayClinical practice guidelines – assist clinicians make knowledge – and experience-based decisions on medical treatment
10 Quality Management and Performance Improvement JCAHO Core Measures – used to assess the quality management efforts of healthcare organizationsQuality Improvement Organizations (QIOs) – work under contract with CMS to conduct quality reviews for Medicare patientsCredentialing – the process of reviewing and validating the qualifications of physicians who have applied for permission to treat patients in the facility.
11 Performance Improvement Systematic look at processes and outcomes to ensure the quality of services provided.Continuous quality improvement (CQI)FOCUS-PDA
12 Utilization Management Focuses on how healthcare organizations use their resourcesUtilization review – a formal process conducted to determine whether the medical care provided to a specific patient is necessary.
13 Risk ManagementPrevent situations that might put hospital patients, caregivers, or visitors in danger.Includes investigating reported incidents, reviewing liability claims, and working with hospital’s lawyers.
14 Legal ProceedingsFour conditions must be met for a health record to be admissible as evidence:The record must have been created as part of the provider’s regular business activitiesThe record must have been maintained as part of the provider’s regular business activitiesThe record must have been created at or near the time that the events occurredThe record must have been created by a person who had first-hand knowledge of the acts, events, conditions, and observations described in the record.
15 Billing and Reimbursement Health record documentation supports the billing and claims management processesTwo main factors determine the amount of payment:The illnesses for which the patient received careThe services and procedures the patient received
16 Diagnostic and Procedural Coding Reimbursement claims communicate information about the patient’s illnesses through the use of diagnostic codesInformation about services and procedures provided to the patient are communicated in the form of procedural codes.
18 Documentation of Medical Necessity Clinicians should indicate the location where each service was performedPhysicians should enter final diagnostic information in the same place in very recordPhysicians should report the results of any preadmission tests or evaluationsPhysicians should document the patient’s specific diagnosis rather than symptoms
19 Documentation of Medical Necessity – cont’d Clinicians should use the same medical terminology throughout the health recordClinicians should document any circumstances that resulted in treatment delays or slowed progressClinicians should indicate the method of administration for medications and treatments
20 Claims ProcessingInvolves calculating charges, preparing and submitting reimbursement forms, and following up to make sure that appropriate payments were made.CMS – 1450CMS – 1500Submitted to third-party payers electronically - EDI
21 Ancillary Functions of the Acute Care Record Accreditation – the process of granting formal approval to a healthcare organizationLicensure – the process of granting an organization the right to provide healthcare servicesCertification – the process of granting an organization the right to provide healthcare services to a specific group of individuals
22 Ancillary Functions of Acute Care Records – cont’d Biomedical Research – the process of systematically investigating subjects related to the functioning of the human bodyHuman subjects studies must meet federal and international guidelinesInformed consent
23 Ancillary Functions of Acute Care Records – cont’d EducationMorbidity and mortality reportingNational Vital Statistics SystemBirthsDeathsIncidences of communicable diseasesManagement of the Healthcare Delivery System
24 Ancillary Functions of Acute Care Records – cont’d Secondary Data SourcesFacility-Specific IndexesMaster patient indexMaster physician indexIndex of diseasesIndex of operations
25 Ancillary Functions of Acute Care Records – cont’d RegistriesA collection of information related to a specific disease, condition, or procedureCancer RegistryProcedure registries
26 Ancillary Functions of Acute Care Records – cont’d Healthcare DatabasesMedicare Provider Analysis and Review File (MEDPAR)National Practitioner Data BankHealthcare Integrity and Protection Data Bank
27 Users of the Acute Care Record “Those individuals who enter, verify, correct, analyze, or obtain information from the record, either directly or indirectly through an intermediary” – IOMCaregiversPatients, patients’ next of kin or legal representativesHealthcare-related organizations