1. Documentation for Acute Care
Chapter 2
Functions of the Acute Care Health Record

2. Introduction
Data – represents objective descriptions of processes, procedures, people, and other observable things and activities
Information – the result of analysis of data for a specific purpose

3. Introduction – cont’d
Initially all health record information was stored in paper format
Handwritten progress notes, paper forms, photographs, graphic tracings, and typewritten reports

4. Electronic Health Record (EHR) movement
Gained momentum since the implementation of HIPAA
Implementation 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 patient
Patient care delivery
Patient care management
Patient care support
Billing and reimbursement

6. Functions of health record in patient care delivery
A data and information collection and storage tool
A service documentation tool
A communication tool for the patient’s caregivers
A diagnostic tool
A tool for patient assessment and care planning
A health record is a risk assessment tool
A discharge planning tool

7. EHR performs several additional clinical functions
Clinical decision support
Error prevention tool
Enhanced discharge planning tool

8. Functions of the health record in patient care management and support
The allocation of the healthcare organization’s resources
The analysis of trends in the usage of patient services
The forecasting of future demand for services
The 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 stay
Clinical 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 organizations
Quality Improvement Organizations (QIOs) – work under contract with CMS to conduct quality reviews for Medicare patients
Credentialing – 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 resources
Utilization review – a formal process conducted to determine whether the medical care provided to a specific patient is necessary.

13. Risk Management
Prevent 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 Proceedings
Four 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 activities
The record must have been maintained as part of the provider’s regular business activities
The record must have been created at or near the time that the events occurred
The 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 processes
Two main factors determine the amount of payment:
The illnesses for which the patient received care
The 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 codes
Information about services and procedures provided to the patient are communicated in the form of procedural codes.

17. Coding Systems
ICD-9-CM
CPT
ICD-10-CM

18. Documentation of Medical Necessity
Clinicians should indicate the location where each service was performed
Physicians should enter final diagnostic information in the same place in very record
Physicians should report the results of any preadmission tests or evaluations
Physicians 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 record
Clinicians should document any circumstances that resulted in treatment delays or slowed progress
Clinicians should indicate the method of administration for medications and treatments

20. Claims Processing
Involves calculating charges, preparing and submitting reimbursement forms, and following up to make sure that appropriate payments were made.
CMS – 1450
CMS – 1500
Submitted to third-party payers electronically - EDI

21. Ancillary Functions of the Acute Care Record
Accreditation – the process of granting formal approval to a healthcare organization
Licensure – the process of granting an organization the right to provide healthcare services
Certification – 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 body
Human subjects studies must meet federal and international guidelines
Informed consent

23. Ancillary Functions of Acute Care Records – cont’d
Education
Morbidity and mortality reporting
National Vital Statistics System
Births
Deaths
Incidences of communicable diseases
Management of the Healthcare Delivery System

24. Ancillary Functions of Acute Care Records – cont’d
Secondary Data Sources
Facility-Specific Indexes
Master patient index
Master physician index
Index of diseases
Index of operations

25. Ancillary Functions of Acute Care Records – cont’d
Registries
A collection of information related to a specific disease, condition, or procedure
Cancer Registry
Procedure registries

26. Ancillary Functions of Acute Care Records – cont’d
Healthcare Databases
Medicare Provider Analysis and Review File (MEDPAR)
National Practitioner Data Bank
Healthcare 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” – IOM
Caregivers
Patients, patients’ next of kin or legal representatives
Healthcare-related organizations