mhis chapter4

Download Mhis chapter4

Post on 22-Jan-2018

284 views

Category:

Healthcare

0 download

Embed Size (px)

TRANSCRIPT

  1. 1. Chapter 4 The Patient Record: Hospital, Physician Office, and Alternate Care Settings Reference: Michelle Green and Mary Jo BOWIE
  2. 2. At the end of this chapter, the student should be able to: 1. Differentiate among various types of patient records 2. Summarize the purpose of the patient record 3. Provide examples of administrative and clinical data 4. Delineate provider documentation responsibilities 5. Summarize the development of the patient record 6. Explain the correct method for correcting documentation 7. Distinguish between manual and automated record formats 8. Discuss the importance of authentication of records 9. Compare alternative storage methods 10. Summarize patient record completion responsibilities Source: Essentials of Health Information Management Green and BOWIE Chapter Objectives
  3. 3. The Patient Record: Hospital, Physician Office, and Alternate Care Settings 9/30/2016 Dr.Mazen Maswady 3
  4. 4. INTRODUCTION TO PATIENT RECORD The manual and electronic patient record has many purposes but only one goal-documentation of patient care. Hospital inpatient records have traditionally served as the documentation source and business record for patient care information; Alternate care facilities that provide behavioural health, home health, hospice, outpatient, skilled nursing, and other forms of care also serve as a documentation source for patient care information Regardless of the type of care provided, a health care facility's patient records contain similar content (e.g., consent forms) and format features (e.g., all records contain patient identification information). 9/30/2016 Dr.Mazen Maswady 4
  5. 5. DEFINITION AND PURPOSE OF THE PATIENT RECORD A patient record serves as the business record for a patient encounter, contains documentation of all health care services provided to a patient, and is a repository of information that includes demographic data, and documentation to support diagnoses, justify treatment, and record treatment results. Demographic data is patient identification information collected according to facility policy and includes the patient's name and other information, such as date of birth, place of birth, mother's maiden name, social security number, and so on. 9/30/2016 Dr.Mazen Maswady 5
  6. 6. DEFINITION AND PURPOSE OF THE PATIENT RECORD Information capture is the process of recording representations of human thought. perceptions, or actions in documenting patient care, as well as device-generated information that is gathered and/ or computed about a patient as part of health care. Typical means for information capture are handwriting, speaking, typing, touching a screen, or pointing and clicking on words, phrases, etc. Other means include videotaping, audio recordings, and image generation through X- rays, etc Report generation, i.e., the construction of a healthcare document (paper or digital), consists of the formatting and/ or structuring of captured information. It is the process of analyzing, organizing, and presenting recorded patient information for authentication and inclusion in the patient's healthcare record. Source :MRI 9/30/2016 Dr.Mazen Maswady 6
  7. 7. DEFINITION AND PURPOSE OF THE PATIENT RECORD The MRl developed the following Essential Principles Of Healthcare Documentation: Unique patient identification must be assured within and across healthcare documentation systems Healthcare documentation must be accurate and consistent, complete, timely, interoperable across types of documentation systems, accessible at any time and at any place where patient care is needed, and auditable Confidential and secure authentication and accountability must be provided The primary purpose of the patient record is to pro-vide continuity of care, which includes documentation of patient care services so that others who treat the patient have a source of information from which to base additional care and treatment. 9/30/2016 Dr.Mazen Maswady 7
  8. 8. DEFINITION AND PURPOSE OF THE PATIENT RECORD According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the purpose of the record is to identify the patient, support treatment provided, document the course of treatment and results, and facilitate continuity of care among health care providers. The record also serves as a communication tool for physicians and other patient care professionals and assists in planning individual patient care and documenting a patient's illness and treatment. 9/30/2016 Dr.Mazen Maswady 8
  9. 9. DEFINITION AND PURPOSE OF THE PATIENT RECORD Secondary purposes of the patient record do not relate directly to patient care and include: Evaluating quality of patient care Providing information to third-party payers (e.g., insurance company) for reimbursement Serving the medico- legal interests of the patient, facility, and providers of care Providing data for use in clinical research, epidemiology studies, education, public policy making, facilities planning, and health care statistics 9/30/2016 Dr.Mazen Maswady 9
  10. 10. Ownership of the Patient Record The medical record is the property of the provider, and as governed by federal and state laws, the patient has the right to access its contents for review (e.g., third-party payer reimbursement) and to request that inaccurate information be amended. (If the provider chooses not to amend the record, the patient can write a letter clarifying the information, which is then filed in the record.) What this means is that the provider owns the documents and maintains possession of original records according to federal regulations 9/30/2016 Dr.Mazen Maswady 10
  11. 11. Hospital Inpatient Record The hospital inpatient record documents the care and treatment received by a patient admitted to the hospital. While the patient is in the hospital, the record is typically located at the nursing station. Some facilities locate the inpatient record in a locking-wall desk (Figure 4-1), and providers enter documentation at the patient's bedside. Administrative data includes demographic, socioeconomic, and financial information. Clinical data includes all patient health information obtained throughout the treatment and care of the patient. 9/30/2016 Dr.Mazen Maswady 11
  12. 12. Hospital Outpatient Record The hospital outpatient record (or hospital ambulatory care record) documents services received by a patient who has not been admitted to the hospital overnight and includes ancillary service (e.g., lab tests, X-rays, and so on), emergency department services, and outpatient (or ambulatory surgery. Since the early 1980s, outpatient services have steadily increased due to cost savings associated with providing health care on an ambulatory instead of an inpatient basis. 9/30/2016 Dr.Mazen Maswady 12
  13. 13. Physician Office Record Patient health care services received in a physician's office are documented in the physician office record. While the content and format of physician office records vary greatly from office to office, they include both administrative and clinical data (Figure 4-3). Generally, physicians who practice independently use a less structured office record while those associated with a group practice use a more structured office record. 9/30/2016 Dr.Mazen Maswady 13
  14. 14. Alternate Care Settings The content of alternate care records depends on the types of services delivered, accreditation standards, and state and federal regulations. There are similarities and differences among the various types of records, but all contain administrative and clinical data. The types of services delivered in the various alternate care settings determine the unique clinical data content of the patient record (Table 4-2). 9/30/2016 Dr.Mazen Maswady 14
  15. 15. Provider Documentation Responsibilities Joint Commission standard IM7.1.1 states that "only authorized individuals may make entries in the medical record." AHIMA recommends that "anyone documenting in the health record should be credentialed or have the authority and right to document as defined by the organization's policy. Individuals must be trained and competent in the fundamental documentation practices of the organization and legal documentation standards. All writers should be trained in and follow their organization's standards and policies documentation 9/30/2016 Dr.Mazen Maswady 15
  16. 16. Provider Documentation Responsibilities Health care providers are responsible for documenting care, treatment, and services rendered to patients in a manner that complies with federal and state regulations as well as accreditation, professional practice, and legal standards. It is important to remember that services rendered must be documented to prove that care was provided and that good medical care is supported by patient record documentation. Thus, inadequate patient record documentation may indicate poor health care delivery; if services provided are not documented, continuity of care is compromised. 9/30/2016 Dr.Mazen Maswady 16
  17. 17. Provider Documentation Responsibilities entries in the medical record." AHIMA recommends that "anyone documenting in the health record should be credentialed or have the authority and right to document as defined by the organization's policy. Individuals must be trained and competent in the fundamental documentation practices of the organization and legal documentation standards. All writers should be trained in and follow their organization's standards and policies documentation 9/30/2016 Dr.Mazen Maswady 17
  18. 18. Provider Documentation Responsibilities NOTE: Providers must remember the famous phrase, "if it wasn't documented, it wasn't done." because the patient record serves as a medicolegal document and the facility's business record, if a provider perf