Healthcare Delivery and Healthcare Delivery and Information Information

ManagementManagement

Healthcare Delivery and Healthcare Delivery and Information Information

ManagementManagement

Instructor: Karen TepeInstructor: Karen TepeWeek 4 SeminarWeek 4 Seminar

General

Thoughts? Concerns? Comments? Anything Goes Here!

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

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

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

HIM Positions in LTC•Health Information Consultant

•Credentialed Health Information Practitioner

•Non-credentialed Health Information Practitioner

•Health Unit Coordinator

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

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

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

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

SeminarQuestions?