1. Healthcare Delivery and Information Management Instructor: Karen Tepe Week 4 Seminar

2. General Thoughts? Concerns? Comments? Anything Goes Here!

3. Record Keeping in LTC Unique health record for each resident –Medical record number (s/b on every page) –Verification in the Master Patient Index (MPI) Separate records for different settings Typically includes the following: –Identification, admission information, consents, H&P, hospital records, assessments, care plans, orders, progress notes, labs, x-rays, therapy records, etc. –Multidisciplinary

4. Record Keeping in LTC Thinning guidelines – see page 28 –Forms identified –Thinned chart (s/b readily accessible) Hospital documents (e.g. H&P) Forms Policy –Indexed –Titled –Approval Committee

5. Record Completion in LTC Frequency –Admission –Concurrent quarterly –Discharge/Death Established Process (see page 35) –Admit/Return 24-48 hours –Admit/Return 14-21 days –RAI Process (Resident Assessment Instrument) –MDS Validation Reports –Concurrent/Quarterly –Discharge Analysis

6. HIM Positions in LTC Health Information Consultant Credentialed Health Information Practitioner Non-credentialed Health Information Practitioner Health Unit Coordinator

7. Health Information Consultant Usually contracted, expert in health information Knowledgeable in LTC regulations, accreditation, etc. Common functions: –Provide assistance in transition to EMR –Resource relating to HIPAA privacy/security issues –Develop policies/procedures – make recommendations –Establish processes for reviewing documentation –Assist with forms development and flow/analysis –Train staff

8. Health Information Credentialed Practitioner Usually hired in lieu of a consultant Knowledgeable in LTC regulations, accreditation, etc. Common functions: –Monitor department budget –Supervise HIM staff –Maintain security of medical record/systems –Manage Release of Information –Overall HIM operations

9. Health Information Non Credentialed Practitioner Generally works with a Credentialed Practitioner or under the direction of a consultant Common functions: (a subset of the credentialed) –Monitor department budget –Supervise HIM staff –Maintain security of medical record/systems –Manage Release of Information –Overall HIM operations

10. Health Unit Coordinator Typically at a Nursing station Common functions: (a subset of the credentialed) –Monitor records for documentation/completion –Thinning records –Filing of documents into in-house records & maintain –Track/schedule routine labs –Prepare paperwork for transfer/referrals

11. Seminar Questions?