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Documentation in Acute Care Chapter 5

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    Documentation in Acute Care Chapter 5 Documentation in Acute Care Chapter 5 Presentation Transcript

    • Documentation in Acute Care Chapter 5 Accreditation and Regulatory Requirements for Acute Care Documentation
    • Mandatory Requirements for Acute Care
      • Federal statutes and regulations
      • State statues and regulations
      • County and municipal ordinances and codes
      • State and federal judicial decisions
    • Legal definitions
      • Statute – a piece of legislation written and approved by a state or federal legislature and then signed into law by the president or the state’s governor
      • Regulation – a rule established by ad administrative agency of government
    • Legal definitions – cont’d
      • Municipal ordinance/code – a rule established by a local government
      • Judicial decision – a ruling handed down by a court to settle a legal dispute.
    • Voluntary Requirements for Acute Care
      • Accreditation organizations – JCAHO, CARF, etc
      • Professional certification organizations – AHIMA, AMA, etc
      • Standards development organizations – ASTM, HL7, etc
    • General Legal Requirements for the Acute Care Record
      • The use of the health records and confidential healthcare information in legal proceedings
      • The form and content of health records and confidential healthcare information
      • The ownership and control of health records and confidential healthcare information
    • Health Records as Legal Documents
      • The health record is generally considered a business record, and has been admissible as evidence in legal proceedings
      • To be admissible in court, the health record must represent one of the persons involved in the legal proceedings.
    • Legal requests for records:
      • Subpoena
      • Subpoena duces tecum
      • Court order
    • Form and Content of Health Records
      • Regulations are usually developed by the state administrative agency responsible for licensing hospitals and other healthcare regulations
        • Records must be maintained
        • Records are complete and accurate
        • Public health reporting, i.e. vital statistics, communicable diseases
    • Ownership and Control of Health Records
      • Generally considered the property of the hospital or healthcare provider that maintains the records.
      • Must remain under the facility’s physical control
      • Patients have the right to control how the personal information in their health records is used to review, copy, and correct the records when necessary
    • Other Health Record Control Issues
      • Release and disclosure
      • Redisclosure
      • Retention/destruction
    • Release and Disclosure of Confidential Health Records
      • Health Insurance Portability and Accountability Act (HIPAA)
        • The patient’s formal consent is not required to use health information for therapeutic, reimbursement, operational, and reporting purposes.
        • Formal consent is required to release or disclose patient information for any other reason.
    • Redisclosure
      • The process of disclosing health record documentation originally created by a different provider.
      • Redisclosure guidelines follow the same principles as the release and disclosure guidelines.
    • Retention of Health Records
      • State laws
      • Statute of limitations
      • Several other records of patient care should be maintained permanently:
        • Master patient index
        • Register of births
        • Register of deaths
        • Register of surgical procedures
    • Destruction of Health Records
      • Paper documents: burning, shredding, pulping, and pulverizing
      • Micrographic film: recycling and pulverizing
      • Optical disks: pulverizing
      • Electronic documents: magnetic degaussing
      • Magnetic tapes: magnetic degaussing
    • Certificate of Destruction
      • Date of destruction
      • Method of destruction
      • Description of the record(s) destroyed, including health record numbers
      • Statement that the record(s) was destroyed during the normal course of business
      • Signatures of the individuals who authorized and witnessed the destruction
    • State and Local Licensure Requirement
      • Developing hospital operating standards
      • Issuing licenses to hospitals that meet the standards
      • Monitoring hospital compliance with the standard
      • Sanctioning hospitals that do not comply with the standards
    • Medicare and Medicaid
      • Established in 1965 by an amendment to the Social Security Act of 1935.
      • The Centers for Medicare and Medicaid Services (CMS) administers the Medicare program and the federal portion of the Medicaid program.
      • Local Medicaid programs are administered by agencies within individual state governments.
    • Medicaid Participation
      • Voluntary for healthcare professionals and organizations
      • Hospitals that choose to participate must apply to the state agency that administers the Medicaid program in their area.
      • Annual surveys are conducted by most states to confirm hospital compliance with Medicaid regulations.
    • Medicare Conditions of Participation
      • Participation is voluntary, however few hospitals would be able to survive economically if they did not provide services to Medicare beneficiaries.
      • Published under title 42, part 482 of the Code of Federal Regulations .
      • Current version became effective, 1/1/2003.
    • Medicare Conditions of Participation Standards
      • Address the organization and staffing of the HIM department.
      • Address health record format and retention requirements.
      • Describes content requirements for acute care documentation
      • Requires hospitals to protect the personal and medical rights of patients.
    • Medicare Conditions of Participation Standards
      • Other sections that include documentation requirements:
        • Medical Staff
        • Nursing Services
        • Radiology Services
        • Laboratory Services
        • Discharge Planning
        • Surgical Services
        • Anesthesia Services
        • Nuclear Medicine Services
    • Deemed Status
      • Granted by Medicare to hospitals that are accredited by JCAHO or AOA’s accreditation programs.
      • CMS requires that approximately 10% of the hospital’s with deemed status undergo a Medicare validation survey.
    • Health Insurance Portability and Accountability Act (HIPAA)
      • Implemented April, 2003
      • Apply to healthcare facilities, professionals, health plans, and health information clearinghouses that transmit healthcare information electronically
    • HIPAA defines health information
      • Any information that is created or received by a healthcare provider in relation to:
        • The past, present, or future physical or mental health of an individual
        • The provision of healthcare services to an individual
        • The past, present, or future payment for healthcare services provided to the individual
    • HIPAA Privacy Standard – A healthcare organization:
      • Can use or disclose confidential patient information for purposes related to its own treatment, reimbursement, and healthcare operations.
      • Can disclose patient information to another healthcare provider for purposes related to the patient’s treatment.
      • Can disclose patient information to another healthcare provider or covered organization for purposes related to reimbursement for services provided to the patient.
    • HIPAA Privacy Standard – A healthcare organization:
      • Can disclose patient information to another covered organization for purposes related to the healthcare operations of the other organization when both organizations have or had a relationship with the individual who is the subject of protected information being requested.
      • That is part of an organized healthcare delivery system can disclose protected health information to another organization within the system for purposes related to the healthcare operations of the system.
    • HIPAA Privacy Standard preempts state laws except when:
      • An exception is made by the secretary of HHS
      • A provision in state law is more stringent than the federal standard
      • The state law relates to public health surveillance and reporting
      • The state law relates to reporting for the purpose of management or financial audits, program monitoring and evaluation, and licensure or certification of facilities or individuals.
    • Requirements for Release and Disclosure
      • Hospital policy must identify the uses and disclosures for which authorization is required.
      • Hospital policy must specify who may authorize disclosure on behalf of an individual patient.
      • Hospital policy must provide special protections for psychotherapy notes.
    • Requirements for Release and Disclosure
      • Hospital policy must establish limitations on the use of protected health information for fund-raising and must provide a mechanism that allows individuals to opt out of fund-raising communications.
      • Hospital policy must establish the requirements for the deidentification of protected health information before it can be released without the patient’s authorization.
    • Requirements for Release and Disclosure
      • Hospital policy must establish a standard to limit the amount of information used or disclosed to the minimum necessary to accomplish the intended purpose.
      • Hospital policy must establish classes of personnel who need access to protected health information, the specific categories of information each class needs, and the conditions under which access is appropriate.
    • Minimum necessary standard
      • Requires the healthcare facility to identify individuals or classes of individuals in its workforce who need access to protected health information.
    • Authorizations for Disclosure must contain:
      • A specific and meaningful description of the information to be used or disclosed
      • The name or other specific identification of the person(s) or class of persons authorized to disclose the information
      • An expiration date or event that relates to the individual or the purpose of the disclosure
      • A statement of the individual’s right to revoke the authorization
    • Authorizations for Disclosure must contain:
      • A statement describing the exceptions to the right of revocation
      • A description of how the individual may revoke the authorization
      • A statement that information disclosed according to the authorization may be subject to redisclosure by the recipient and so would not longer be protected
      • The signature of the individual and the date
    • Authorization is considered invalid if:
      • The expiration date or event has already passed
      • The authorization has not been filled out completely
      • The covered party knows that the authorization has been revoked
      • The authorization lacks one or more of the required elements
      • The authorization is a prohibited type of authorization or covers more than one request
      • The covered entity knows that part of all of the information in the authorization is false
    • HIPAA Security Standard
      • Calls for providers to develop security policies, procedures, contracts, and plans.
      • Requires the implementation of physical and technical safeguards to protect confidential health records and information.
    • Physical safeguards include:
      • Environmental safety systems such as fire alarms, smoke detectors, and sprinkler systems
      • Surveillance systems and other methods of controlling and monitoring access to the facility
      • Media control systems that prevent unauthorized access to computer equipment and work stations
    • Technical Security Mechanisms and Procedures
      • Access control technology
      • Data authentication
      • Audit trails
      • Encryption technology
    • HIPAA Administrative Requirements
      • Every facility must designate a specific individual to manage its privacy program
      • Every facility must designate a specific to answer requests for privacy information and respond to privacy-related complaints
      • Every facility must train its employees and medical staff on the provisions of its privacy and security policies
    • HIPAA Administrative Requirements – cont’d
      • Every facility must establish appropriate administrative, technical, and physical safeguards to protect confidential health information
      • Every facility must develop contingency plans that address information system backup, disaster recovery, and emergency operating procedures
      • Every facility must establish health record content and clinical documentation policies and procedures
    • HIPAA Administrative Requirements – cont’d
      • Every facility must specify policies and procedures related to privacy notifications, authorizations for disclosure, health record corrections and amendments, disclosure documentation, complaint handling, and overall HIPAA compliance
      • Every facility establish the copying fees to be charged for disclosure
    • Special Protection Requirements
      • Records of psychiatric care and psychotherapy
      • Records of substance abuse treatment
      • Records of HIV/AIDS diagnosis and treatment
      • Records that contain genetic information
    • Psychiatric Care and Psychotherapy Records
      • Psychiatric records include two separate records
        • Official record – that documents the patient’s care and treatment
        • Personal record – which documents the clinician’s experience and conversations with the patient
        • Release of psychotherapy notes requires a specific authorization
    • Substance Abuse Treatment Records
      • The Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act
      • The Drug Abuse Prevention, Treatment, and Rehabilitation Act
      • Both passed in 1970, amended in 2000
      • Apply to programs operated, regulated, or directly or indirectly funded by the federal government.
    • Records of HIV/AIDS Diagnosis and Treatment
      • Many states have HIV/AIDS reporting requirements and antidiscrimination laws
      • HIV Testing
        • Basically voluntary in US
        • May be mandatory for specific groups of employees
    • Confidentiality Issues related to HIV/AIDS
      • Consent for testing
      • General information on testing
      • Reporting of test results
    • Records that contain Genetic Information
      • Protected under state health record regulations
      • HIPAA addresses health insurance discrimination based on genetic information
    • Accreditation Requirements for Acute Care Hospitals
      • Accreditation – a systematic quality review process that evaluates the healthcare facility’s performance against preestablished written criteria, or standards.
      • JACHO, AOA, CARF, AAAHC, NCQA
    • Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
      • Accredits over 17,000 healthcare organizations in the US
      • Primary mission:
        • To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations.
    • Organizations eligible of JCAHO accreditation:
      • Acute care hospitals
      • Critical access hospitals
      • Children’s hospitals
      • Psychiatric hospitals
      • Rehabilitation hospitals
      • Ambulatory care organizations
      • Behavioral health organizations
      • Home care agencies
      • Long-term for skilled nursing facilities
      • Healthcare networks
      • Clinical laboratories
    • JCAHO’s Shared Visions-New Pathways
      • Implementation began, January, 2004
      • Focuses on systems critical to the safety and quality of patient care, treatment, and services.
      • Emphasis in JCAHO accreditation shifted away from triennial survey preparation to continuous improvement philosophy that applies to every area of the facility.
    • Elements of JCAHO accreditation manual
      • The standard – a concise statement of the goal
      • The rationale for the standard – explains why achieving the goal in important
      • The elements of performance (EPs) – the steps to be followed in meeting the goal
    • Scoring method applied to EPs
      • 0 – Insufficient compliance
      • 1 – Partial compliance
      • 2 – Satisfactory compliance
      • 3 – Not applicable
    • JCAHO’s Management of Information
      • Identification of the hospital’s information needs
      • Structure of the hospital’s information management system
      • Processes for capturing, organizing, storing, retrieving, processing, and analyzing clinical data and information
      • Processes for transmitting, reporting, displaying, integrating, and using clinical data and information
      • Processes for safeguarding the confidentiality and integrity of clinical data and information
    • JCAHO Sentinel Event Policy
      • “An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof”
      • Hospital’s need processes in place to identify and manage sentinel events
    • JCAHO Survey Process
      • Periodic performance review (PPR) – an organizational self-assessment to be conducted at the halfway point between triennial on-site surveys.
      • Followed by a telephone discussion with the hospital’s representative about a plan of action for shortcomings identified in the PPR.
    • JCAHO Survey Process
      • Application is filed as hospital nears the end of its three-year accreditation cycle
      • Priority focus process (PFP) – converts presurvey data into information that focuses survey activities, increases consistency in the accreditation process, and customizes the accreditation process to make it specific to the hospital.
    • PFP Sources of Information
      • Core measure data
      • Previous survey findings
      • Sentinel event data
      • Complaints about the hospital submitted to JCAHO
      • Data submitted by the hospital
      • External, publicly available data
    • Priority Focus Areas (PFAs)
      • Processes, systems and structures that can have a substantial effect on patient care services.
    • JCAHO on-site survey agenda
      • Opening conferences and orientation to the hospital
      • Survey planning meeting
      • Unit visits guided by priority focus information and patient tracers
      • Assessment of the medical staff credentialing process
      • Assessment of environments of care
    • JCAHO on-site survey agenda
      • System tracer conferences
      • Interviews with staff
      • Interviews with hospital leaders
      • Assessment with hospital leaders
      • Assessment of standards compliance
      • Environment-of-care issues resolution
      • Exit conference
    • Tracer Methodology
      • An evaluation that follows (traces) the hospital experiences of specific patients.
      • Surveyors are able to evaluate ho well the hospital’s processes and departments work with each other.
      • Surveyors interview the physicians and staff involved in each patient’s care as well as the patients themselves when possible.
    • JCAHO Accreditation Decisions
      • Accredited
      • Provisional accreditation
      • Conditional accreditation
      • Preliminary denial of accreditation
      • Denial of accreditation
      • Preliminary accreditation
    • American Osteopathic Association (AOA)
      • Primary certification agency for all osteopathic physicians
      • Accreditation agency for all osteopathic medical colleges and many osteopathic healthcare facilities
      • Accreditation process initiated in 1945
      • Healthcare Facilities Accreditation Program (HFAP)
    • Healthcare Facilities Accreditation Program accredits:
      • Laboratories
      • Ambulatory care clinics
      • Ambulatory surgery centers
      • Behavioral health and substance abuse treatment facilities
      • Physical rehabilitation facilities
      • Acute care hospitals
      • Critical access hospitals
    • Commission on Accreditation of Rehabilitation Facilities (CARF)
      • Healthcare accreditation programs in the areas of:
        • Medical rehabilitation
        • Behavioral health
        • Adult day care and assisted living
        • Employment and community services
    • CARF Survey Process
      • Scheduled in advance
      • Opening conference
      • Document review
      • Interviews with program staff and patients
      • Exit interview with organization’s leaders
    • CARF Accreditation Decision Process
      • Based on an objective assessment of the facility’s performance compared to CARF standards.
      • Standards Conformance Rating System
        • 0 Nonconformance
        • 1 Partial conformance
        • 2 Conformance
        • 3 Exemplary conformance
    • Other accreditation organizations
      • Accreditation Association for Ambulatory Healthcare (AAAHC) – establishes standards for outpatient documentation that are similar to acute care documentation practices.
      • National Committee for Quality Assurance (NCQA) – a private not-for-profit organization dedicated to improving health quality by conducting assessments of managed care and other healthcare programs in the US.
    • Corporate Negligence
      • Legal doctrine established by a judicial decision in the Darling v. Charleston Community Hospital in 1965.
      • The hospital’s governing boards have a “duty to establish mechanisms for the medical staff to evaluate, counsel, and when necessary, take action against an unreasonable risk of harm to a patient arising from the patient’s treatment by a personal physician.”
    • Credentialing Process
      • Verification of the applicant’s undergraduate, medical, and postdoctoral education
      • Verification of the applicant’s residency and fellowship training as well as continuing medical education
      • Past and current medical staff appointments at other facilities
    • Credentialing Process
      • Current state licenses to practice medicine
      • Current specialty board certifications
      • Current drug enforcement administration registration
      • Documentation of professional liability insurance
      • References and recommendations from the applicant’s professional peers
    • Credentialing Process
      • Information on the applicant’s health status
      • Past and current liability status
      • Inquiries to two national databases:
        • National Practitioner Data Bank (NPDB)
        • Healthcare Integrity and Protection Data Bank (HIPDB)
    • Privileging Process
      • Granted by the governing board
      • Authorize the practitioner to provide patient services in the hospital but only those service that fall within his/her areas of expertise.
    • Risk Management
      • The process of overseeing the hospital’s internal medical, legal, and administrative operations with the goal of minimizing the hospital’s exposure to liability.
      • Liability – the legal responsibility to compensate individuals for injuries and losses sustained as the result of negligence.
    • Reportable Incident
      • An event that is considered to be inconsistent with accepted standards of care.
      • Incident report – describes the occurrence, its time, date, and location, the identify of the individual or individuals involved, and the current condition of the individual(s) involved in the incident.
    • Health Data Standards
      • Health care data sets (UHDDS, EMEDS, HEDIS, UACDS)
      • Health Informatics Standards – uniform methods for collecting, maintaining, and/or transferring healthcare data among computer information systems
    • Standards Development Organizations
      • Design scientifically based models against which structures, processes, and outcomes can be measured.
        • American National Standards Institute (ANSI)
        • United Nations International Standards Organization (ISO)
    • Health Informatics Standards
      • Vocabulary standards – to establish uniform definitions for clinical terms
      • Structure and content standards – to establish clear descriptions of the data elements to be collected
      • Transaction and messaging standards – to facilitate electronic data interchange (EDI) between independent computer information system
    • Health Informatics Standards
      • Security standards – to ensure the confidentiality of patient-identifiable health information and to protect it from unauthorized disclosure, alteration, and destruction
      • Identifier standards – to establish methods for assigning unique identifiers to individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers
    • Health Informatics Standards organizations
      • Health Level Seven (HL7)
      • EHR Collaborative
      • American Society for Testing and Materials (ASTM)
      • SNOMED Clinical Terms (SNOMED CT)
    • Internal Hospital Policies and Procedures
      • Policies – general written guidelines that dictate behavior or direct and constrain decision making within the organization.
      • Procedures – written instructions that detail how functions and processes are to be carried out.
    • General categories of hospital policies
      • Administration, including HIM
      • Medical staff
      • Nursing services
      • Human resources
      • Safety
      • Environment of care