HM480

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Health Information
Management: Concepts,
Principles, and Practice
Sixth Edition
Chapter 4
Health Record Content and Documentation

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Evolution of the Health Record
• Historical overview
• Factors influencing health record content
• Provider preference
• Information required to provide healthcare
• Data sets that require certain data elements
• Accreditation and certification standards

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Health Record Documentation Standards
• American College of Surgeons
• Joint Commission formerly the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO)
• Medicare Conditions of Participation
• State licensure requirements
• Internal organizational standards including bylaws,
rules and regulations

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Functions of the Health Record
• Ongoing care and treatment of individual patients
• Clinical decision making and communication
• Reimbursement including meaningful use
• Evaluation of the quality and efficacy of care
• Medical research and education
• Operational management
• Legal purposes

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Responsibility for quality documentation
• Role of HIM professionals in ensuring data accuracy
• Current issues
• Copy paste functionality
• Correcting and amending the health record
• Patient identity management

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Content of the Health Record
• Administrative and demographic information
• Demographic Information
• Consent to treatment
• Consent to use or disclose protected health record
information
• Advance directives
• Acknowledgment of patient’s rights information
• Property and valuables list

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Content of the Health Record (continued)
• Clinical data
• History and Physical
• Medical history
• Physical examination
• Diagnostic and therapeutic orders
• Special types of orders
• Discharge orders
• Clinical observations
• Progress notes
• Medication administration records
• Lab and radiology reports
• Operative reports
• Autopsy report
• Organ transplant report
• Obstetrical reports

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Content of the Health Record (continued)
• Conclusions at termination of care
• Discharge Summary
• Discharge Plan
• External records filed with the health record
• PHRs
• Social media and electronic communication

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Specialized Health Record Content
• Emergency care
• Ambulatory or outpatient care
• Behavioral healthcare
• Home healthcare
• Hospice care
• Rehabilitation services
• Long-term care

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Formats of the Health Records
• Source-oriented health records
• Problem-oriented health records
• Integrated health records

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Management of Health Record Content
• The next unit discusses several of the areas that the
HIM professional is responsible for that result in a
complete and accurate health record.

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Transcription Services
• Components of the transcription service
• Digital Dictation
• Transcriptionist
• Planning for transcription services
• Internal versus outsourced
• Staffing
• Productivity management
• Incentive programs
• Speech (voice) recognition technologies
• Turn around times for reports

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Abstracting
• Reviewing the patient record and collecting data
elements
• Purpose is to make information available for
internal/external reporting needs for:
• Registries
• Public reporting
• Research
• Process of collecting data from the following:
• Paper-based health records
• Hybrid health records

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Incomplete Record Control
• Quantitative analysis or Discharge analysis
• Are all reports/notes present and signed?
• Concurrent analysis
• Universal chart order
• Adequacy of documentation
• Record completion policies and procedures
• Qualitative analysis
• Do all reports/notes include required data elements and
is information accurate?
• Closed record review

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Authentication of Health Record Entries
• Authentication: proof of authorship
• Methods of authentication
• Clinicians’ handwritten signatures
• Clinicians’ electronic signatures

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Record Completion Polices and Procedures
• Role of HIM professionals
• Role of the medical staff

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Management of Incomplete Records
• Storage, retrieval, and tracking
• Policies and procedures
• Delinquent health records
• Chart tracking
• Physician notification process

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Template (Forms) Design and Management
• Principles of template (forms) design
• System downtime procedures including printing
forms
• Forms control guidelines
• Develop forms according to established guidelines
• Control the printing and use of paper forms and
integration of new screen designs or electronic
templates
• Guide providers in designing forms and templates
according to established guidelines
• Prevent staff from changing or designing forms that
duplicate existing forms

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Health Record Life Cycle
• Health record creation and identification
• Unit numbering
• Serial-unit numbering
• Health record filing systems
• Straight numeric filing
• Terminal digit filing
• Patient identity management

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Health Record Life Cycle (continued)
• Master patient index (MPI), also known as:
• Master person index
• Master name index
• Enterprise-wide master person (or patient) index (EMPI)
• Duplicate record entries
• Overlaps
• Overlays

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Health Record Life Cycle (continued)
• Ensuring accurate patient matching in health
information exchange and sharing patient records
with other facilities.

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Health Record Life Cycle (continued)
• Content of the master patient index
• Patient’s full name, birth date, and address
• Patient’s health record number and billing account
number
• Name of attending physician
• Dates of admission and discharge or date of visit or
encounter
• Disposition at discharge or conclusion of care
• Patient’s date of death, if applicable
• Patients marital status, gender, and race
• Name of emergency contact

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Health Record Life Cycle (continued)
• Health record storage and retrieval
• Equipment
• Space
• Supplies

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Health Record Life Cycle (continued)
• Development of Record Retention Program
• Program objectives
• Elements to consider in the preservation of records

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Health Record Life Cycle (continued)
• Accreditation and legal health record retention
requirements
• Retention requirements for ancillary materials
• Destruction and transfer of health records
• Development of retention program
• Use of microfilming and optical scanning
• Methods and records of destruction
• Destroying unnecessary records
• Dealing with outdated media