HEALTH INFORMATION/ RECORD MANUAL

Health Information Record Systems ApprovalApproval/Health Information/Record

Management SystemsResponsibility for Records/Signature

Regulatory Documentation RequirementsCalifornia (#0030)Iowa (#0031)Kansas (#0032)Missouri (#0033)Nevada (#0034)New Mexico (#0035)Texas (#0036)

Health Information/Record Service OrganizationIntroduction – Defines the

Clinical communication tool used among health care providers;

A legal document that describes the health care services provided to the resident.

IntroductionEach resident admitted to the center will have:

A record (electronic and/or paper) initiated on admission;

Completed in accordance with state and federal regulations;

Accepted professional practices with formalized systems in place;

Maintenance of records;Records are readily accessible;Accurate both manual and electronic.

HIPAAGuidance in the Health Insurance Portability

and Accountability Act. 1996 (HIPAA) [45 C.F.R. 164.5…], Department of Health and Human Services Part 160 and 164 Breach Notification for Unsecured Protected Health Information and any subsequent HIPAA rules and applicable other State and Federal laws/regulations.Refer to Skilled HC.

OrganizationRecord Responsibility (#1015) –

See sample on following slideInterview Tool Questions (#1016) –

See sample on following slideInterview Tool Answers (#1017)Job Description Health Information Director

(#1020)Job Description Regional HI Management

Coordinator (#1025 – See Skilled HC)

Record Responsibility (Sample)

Interview Tool Questions (Sample)

Organization -2

Staff Development/Orientation/Training (#1035) – See sample on following slide

Lesson Plan & Attendance Sheet (#1036)Health Information Director Orientation Training &

Evaluation Checklist (#1037)Performance Measures / Staff Competencies /

Training Guide (#1038) – See sample on following slide

Health Information / Record Department System Skills Evaluation (#1039)

Health Information/Record System Department Report to Administrator (#1040)

Staff Development /Orientation / Training (Sample)

Performance Measures /Staff Competencies (Sample)

Clinical Record Service/General PoliciesLegal Medical Record & Related

Policies/Procedures (#2007) – Also Skilled HC Review

Definition of Record Set (#2008)General Record Policies / Documentation

Guidelines (#2010)

Clinical Record Service/General Policies -2

Resident Record Content (#2015)Admission Record/Face SheetAdvance Directive Acknowledgment / POLSTAllergiesAlternate Schedule of Physician VisitsAncillary AssessmentsBehavior Drugs/PsychotropicBowel/Bladder AssessmentCare Plan/Plan of Care Certification/RecertificationComprehensive Resident Assessment Instrument

(MDS)

Clinical Record Service/General Policies -3

Resident Record Content (#2015)…cont.Consents/RightsConservatorshipConsultation ReportsDiagnosesHistory/PhysicalIndividual Health Care InstructionInterdisciplinary Discharge SummaryInterfacility Transfer Report/SummaryLaboratory/X-Ray/Diagnostic ReportsLeave of Absence/Pass RecordLength (Height)/Weight

Clinical Record Service/General Policies -4

Resident Record Content (#2015)…cont. Licensed Nursing Notes MedicareMedication and Treatment AdministrationMinimum Data Set (MDS)MonitorsMortician’s ReceiptNotification to PhysicianNurse Practitioner – see Physician VisitsNursing Assistant NotesPharmacy ReviewPhysician Assistants – see Physician Visits

Clinical Record Service/General Policies -5

Resident Record Content (#2015)…cont. Physician Extenders – see Physician VisitsPhysician OrdersPhysician Progress NotesPhysician VisitsPhysician’s Discharge SummaryPlan of Care – see Care PlanPossessions ListPreferred Intensity of Care/No CPR/DNR RequestPsychotropic – see Behavior DrugsRehabilitative/Specialized TherapyResident Data Set

Clinical Record Service/General Policies -6

Resident Record Content (#2015)…cont. Restorative NursingRestraints-PhysicalSmokingSurrogate Decision MakerThirty-Day Notice Tuberculosis ScreeningTurningVital signsWeight

Willful Falsification / Willful OmissionWillful Falsification/Willful Omission (#2025)

Readmission/Record ProcessReadmission (#3005)

By State

Discharge ProceduresOrder of Filing/Shortened Discharge Chart

(#3501 - #3507) - By State Discharge Chart Monitor (#3520) – See

sample on following slideIncomplete Record Procedure (#3525)

Discharge Chart Monitor (Sample)

Health Information/Record TasksGuide to Location of Items in Health

Information / Record Department (#4005)Record Tasks (#4010)Monitoring Schedule (#4011) – See sample on

following slideNumber System/Filing (#4020)Unit Record (#4025)

Monitoring Schedule (Sample)

Establishing and Closing the Record, Filing, ClearanceEstablishing/Closing the Record (#4030)In-House Order of Filing (#4031 - #4037) – By

StateClearance of Records / Thinning (#4040)

Establishing and Closing the Record, Filing, Clearance -2

Retrieval of Records – Chart Locator System (#4050)

Lost Record / Reconstruction (#4055)Storage of Records / Destruction After

Retention Period (#4060)Off-Site Storage of Records (#4065)Retention of Records – General

(#4070)

Indices/Registries/Coding, OtherIndices/Registries (#5005 – Refer to Skilled

HC)Master Resident Index (#5010)Monthly Review of Physician Orders (#6005 –

Refer to Skilled HC)Delinquent Visit/Follow-Up (#6010)

Disaster Planning, Ancillary Log, Committee MinutesDisaster Planning for Health Information

(#6015 – Refer to Skilled HC)Laboratory/X-Ray Log (#6020 – Refer to

Skilled HC)Guidelines for Committee Minutes (#6025 –

Refer to Skilled HC)

Confidentiality/Security of Health Information – Refer to Skilled HC)Notice of Privacy Practices (#7001 )Reporting of Unlawful/Unauthorized Access, Use and

Disclosure of Protected Health Information (#7002)Use & Disclosure of PHI – Minimum Necessary (#7003)Resident Access to Records (#7007)Amendment/Addendum to Records (#7009)Subpoena (#7011)Ombudsman/Review of Records (#7013)Accounting/Tracking of Disclosures (#7015)Facsimile (Fax) Machines (#7017)Confidentiality/Security of Information –

Manual/Automated (#7019)Training in Privacy Regulations (#7021)

Monitors/Completion InstructionsMonitor Schedule – See #4011Monitors – with Policy/Procedure and

Instructions (alphabetized) – Section 7050Admission MonitorChange of Condition Monitor

- See sample on following slideCNA / ADL Flow Sheet MonitorGeneral Update / Clinical Record Monitor

(Pacific Region)General Update Log (Central/Midwest Regions)

Monitors/Completion Instructions -2

Monitors – with Policy/Procedure and Instructions (alphabetized) – Section 7050Medication / Treatment MonitorPressure Sore/Ulcer/Skin Conditions Monitor

COC Monitor (Sample)

Additional Monitors – with Brief Instructions - Section #7051Advance Directive/IHCI/Preferred Intensity of

Care (PIC) /Physician Orders for Life Sustaining Treatment (POLST) Monitor

Behavior Drug MonitorBowel/Bladder Training MonitorCare Plan Monitor (Future)Diabetic MonitorDialysis MonitorHospice Monitor

Additional Monitors – with Brief Instructions - Section #7051 -2

Intake/Output/Catheter Monitor (Future)Licensed Progress Note MonitorRespite Care Monitor (Future)Restrictive Device/Restraint MonitorWeight Monitor/Weekly Weight

Monitor/Weight Log - See Skilled HC

Additional Monitors – with Brief InstructionsMedication/Treatment Self Monitor (#7052 –

Future)Monitors/Completion Instructions – EHR

System (#7053 – Future)Monitors/Completion Instructions – Manual

(#7054 – Future)

Resident Assessment/Prospective Payment System/MedicareElectronic Signatures (#8020 – Refer to

Skilled HC)Medicare Log (#8025 – Refer to Skilled HC)Medicare Certification/Re-Certification (#8030

– Refer to Skilled HC)

MiscellaneousAbbreviations/Symbols (#9005 – Future)Request for Hospital Information – Sample

Letter to Acute Hospital for Records (#9010)

Hyperlinks to State Regulations – Appendix ACalifornia IowaKansasMissouriNevadaNew MexicoTexas

HIM Record Manual Questions or Corrections – Appendix BContact rhonda@ahis.net and trisha@ahis.net

for any updates, changes, etc.Or fax to AHIS’ office at 714-558-1302

Questions?Rhonda L. Anderson, RHIA

PresidentAnderson Health Information Systems, Inc.

940 W. 17th Street, Suite BSanta Ana, CA 92706

Tel. 714/558-3887Mobile 714/299-0573

rhonda@ahis.net