Health Records in Other Settings Ambulatory CareRehabilitation Long Term CareHome Care Mental Health Hospice

Why There are Differences  The type of setting  The type of services  The type of patients served

Differences  External factors JCAHO Other regulatory bodies that may accredit a facility State and local laws Rules that apply to facilities that receive funding from the federal government

Similarities  All facilities should document to Ensure continuity of care Justify reimbursement Protect the facility or the patient in legal proceedings Contribute to research and education

Emergency Room Records  Documentation is limited to information about the patient’s presenting problem  Important to document: Instructions given to patient Patients presenting complaint Evaluation Assessment

Emergency Room Records  See list of standard information required, text book page 73

Ambulatory Care  Many forms are similar to those used in hospitals  Unique to ambulatory care may be: Problem list Medications list Patient history questionnaire  Usually the patient fills out a history form themselves. In the hospital the physician does this.

Ambulatory Surgery Records  Very similar to records in a hospital-based surgery department

Ambulatory Surgery Records  Medicare requires Patient ID History & Physical Preoperative studies Findings and techniques of the operation including pathology reports

Ambulatory Surgery Records  Medicare requirements, cont… Allergies and abnormal drug reactions Record of anesthesia administered Informed consent to treatment Discharge diagnosis

Ambulatory Surgery Records  Should also include documentation of: The patient’s course in the recovery room Routine follow-up phone call or visit

Long Term Care (LTC)  The regulations that govern long term care facilities have established strict documentation standards Most are governed by both federal and state regulations Most do not participate in voluntary accreditation processes

Long Term Care  Records are based upon ongoing assessments and reassessments of the patient’s needs RAPS – Resident Assessment Protocols  The health care team develops a plan of care for each patient and the plan is regularly updated

Long Term Care  Resident Assessment Instrument (RAI) is the format for the care plan that is required by federal regulations  The plan is reassessed on a quarterly and annual basis and whenever there is a significant change in patient’s condition  The RAI is a critical component of the health record

Long Term Care  MDS – Minimum Data Set Medicare form used to determine Medicare reimbursement Many states also use it to determine Medicaid reimbursement Accreditors or licensors use the information during the survey process

Long Term Care  Centers for Medicare and Medicaid Services (CMS, formerly HCFA) uses MDS data to compile information on demographics and quality indicators  Feedback is provided to each family

Long Term Care  Unique to LTC is that most documentation is done by nurses and other health care providers rather than physicians  Physician develops the plan of treatment  Physician visits patient on a day schedule and reviews treatment plan and makes updates/orders as needed

Home Health Care (HHC)  Huge growth in this area  Patient’s desire to be at home for as long as possible has fueled this industry  Cost savings as compared to residential facilities

Home Health Care  Medicare regulations and accreditation standards have established documentation requirements  Mandate periodic assessments  Plan of Care is a central component of documentation  Plan of Care is established by the physician ordering treatment

Home Health Care  Plan of Care Physician must renew plan every 60 days Updates can be made by telephone orders from physician Physician visits in the home are not required Patients may be required to visit the physician

Home Health Care  OASIS Outcomes and Assessment Information Set Medicare form Standardized assessment form Foundation for the plan of care Basis for Medicare reimbursement Submitted electronically to CMS

Home Health Care  Unique to home care is a service agreement Details the type and frequency of services, the charge for the services, and the parties responsible for payment

Home Health Care  Documentation depends on the services ordered  Each visit must be documented  Challenge of maintaining records when caregivers are not in a central location  Some parts of the record may be kept in patient’s home to allow for effective communication between caregivers

Home Health Care  Record maintenance issues How do documents get to main office? How often? Who tracks this?  Security issues Care providers driving from home to home with confidential documentation in their car  Electronic record would be ideal

Home Health Care  See list of other typical documentation, in text book page 78

Hospice  Basic ID date  Plan of Care and documentation of care given  Palliative care Keeping the patient comfortable and as pain free as possible  Care plan is reviewed every 30 days  Federal regulations and accreditation standards guide hospice documentation

Hospice  Care continues even after death of patient Follows the family through the bereavement process and can last as long as one year

Behavioral Health Care  Mental Health  Delivered in a variety of settings Inpatient hospitals Outpatient clinics Rehabilitation programs Community mental health programs

Behavioral Health Care  Documentation requirements differ in each setting  See the minimum documentation requirements unique to the behavioral health setting established by JCAHO on page 79 of text book

Rehabilitation Services  Health record documentation reflects the level of care provided  CARF – Commission on Accreditation of Rehabilitation Facilities The accreditation body for rehabilitation facilities  CARF requires a record for each patient

Rehabilitation Services  Evaluations and recertifications every days Often have to be mailed to physician for signature  See documentation requirements on page 80 of text book

Job Preparation  As long as you know “the basics” and can transfer that knowledge to the different types of facilities, you will be able understand and adapt to the health information systems at different types of facilities