QUESTION: What is the purpose of having a health record? (To provide diagnosis and treatment records for every individual assessed or treated) The health record should: Document a patient ’ s life and health history. Include past and present illnesses and treatments. Review events during the current episode of care. Be compiled in a timely manner. Contain sufficient data to identify the patient. Support the diagnosis or reason for healthcare encounter. Justify the current treatment and accurately document the results. TRANSITION: According to Abdelhak ’ s Heath Information: Management of a Strategic Resource, the medical record serves 5 purposes.
A patient ’ s health history can provide context for the current illness and alert the physician to medical contraindications Allows clinicians to communicate the plan of care for the patient with others involved in the patient ’ s care Is a legal document of care and services provided Is a source of data Is a resource for healthcare practitioner education
The patient ’ s record may come in several formats or hybrids. As electronic formats advance, paper notes become obsolete. The traditional medical record is paper. Most hospital medical records are in a state of transition going from paper to electronic. Advantage of electronic records: many users are able to access the record at the same time. Documentation serves as the basis of a health record.
The Centers for Medicare and Medicaid Services (CMS) have provided physicians with General Principles of Medical Record Documentation.
General principles of Medical Record Documentation: The rationale for ordering diagnostic and ancillary services (If not documented, they should be easily inferred) Past and present diagnoses should be accessible to all providers Appropriate health risk factors should be identified Patient ’s progress, response to changes in treatment, and revision of diagnosis should be documented
Some of the UHDDS data elements included are personal identification, date of birth, sex, race, residence, admit date, and discharge date.
Records may be organized in a reverse chronological order. QUESTION: Why would the clinical records be organized in reverse order? (More definitive diagnostic statements can perhaps be made toward the end of the patient stay.) The discharge summary may begin the record.
QUESTION: Name some other elements that are required by UHDDS. (Sex, Race and ethnicity, Residence, Hospital ID number, Admission date, Type of admission, Discharge date, Diagnoses, Procedures and dates, External cause of injury code, Birth weight of neonate, Disposition of the patient, Patient ’ s expected source of payment, Total charges) TRANSITION: Now we will discuss the clinical data elements in more detail.
Chief complaint (CC): Reason in the patient ’ s own words for the visit Other elements: History, physical exam, possible labs and/or radiology reports, plan of care, physician orders, procedures performed, working diagnoses, disposition of the patient
The Joint Commission requires that the H&P be completed within 24 hours DISCUSSION QUESTION : Why do you think it is important for the History and Physical to be on the medical records within 24 hours? ( So that the clinical staff and consulting have the information to treat the patient. )
QUESTION: Who puts information in the physician orders? (Attending physician or physician consultants) Gives directions to other physicians and nursing and ancillary services May be written or verbal and part of written or electronic records. Verbal orders guided by medical staff regulations Verbal and telephone orders must be signed by the physician giving the order within 48 hours after giving the order QUESTION: List some required elements of a physician order. (Dated, timed, and signed)
Records the course of the patient ’ s hospital care Normally written by the attending physician Other clinicians will also be using the record: Academic medical centers: Medical students, interns, residents Integrated progress notes: Several disciplines write in the same area of the record (physical therapists, respiratory therapists, and sometimes nursing) Records may be scribed by someone other than the physician EHR notes may be dictated and transcribed or typed by the physician Recorded on a daily basis. Frequency of notes governed by medical staff regulations.
There must be an operative report if patient is having a surgical procedure Must be on record within 24 hours of time after procedure was performed
Summary of the patient ’ s stay in the hospital TRANSITION: Now that we have looked at the sections of the health record, we will discuss the standards for reporting the content.
Extract the diagnoses and procedures The extracting of data from the health record may also be referred to as abstracting
The most important concept to understand and to apply: Principal diagnosis and principal procedure create the Medicare severity diagnosis-related group MS-DRGs determine reimbursement A coder ’ s main role is to select the correct diagnosis upon record review Sometimes the principal diagnosis is not easily identifiable Some diagnoses may utilize more resources during a patient stay but will not be the principal diagnosis
Must have significance for the specific hospital encounter Other diagnoses: “ Conditions that coexist at the time of admission, or develop subsequently or affect the treatment received and/or the length of stay ” Do not use diagnoses which relate to an earlier episode which have no bearing on the current stay “ Other diagnoses ” affect patient care in terms of requiring: Clinical evaluation; or Therapeutic treatment; or Diagnostic Procedures; or Extended length of hospital stay; or Increased nursing care or monitoring Other diagnoses may become complications and/or comorbidities Important in the MS-DRG system of reimbursement
The coder would expect to see some testing, clinical observations or perhaps a consultation
Treatment by medications, physical therapy, and surgery are forms of therapeutic treatment. Physicians often list conditions in the patient ’ s past medical history that are currently being treated The coders should be familiar with medications and the disorders they treat
Used to determine the cause of a sign, symptom, or patient complaint, and to determine the underlying cause. QUESTION: Name some possible diagnostic procedures : EKG or ECG (electrocardiogram); EEG (electroencephalogram); EGD (esophagogastroduodenoscopy); Colonoscopy; Echocardiogram; Nuclear medicine studies; MRI (magnetic resonance imaging); MRA (magnetic resonance angiography); X-rays
Patient is ready to be discharged but develops a condition requiring either more investigation, monitoring, or watchful waiting Needs an additional night ’ s stay Examples of conditions: fever, cough, or pain
Appropriate for conditions that are not significant enough to require physician treatment Physician may order additional care or labs to monitor the condition If there is no physician diagnosis for which care is being rendered, query the physician
The discharge summary or history and physical will list diagnoses from previous admissions that are NOT applicable to the current hospital stay These are NOT reported and are coded only if required by hospital policy “ History of ” codes may be used if this historical condition has an impact on current care or influences treatment
Patients may have multiple chronic conditions when they are admitted May not be specifically treated with medications or procedures Report them because they may be evaluated and/or monitored, or affect the way a patient is treated. Long-term use of medications such as anticoagulants are a clue. QUESTION: Name some chronic conditions that may be used as additional diagnoses . (Such as, but not limited to, hypertension, congestive heart failure, asthma, emphysema, COPD, Parkinson ’ s disease, and diabetes mellitus)
Conditions that are an integral part of the disease process are not coded Conditions that are NOT an integral part of the disease process may be coded
“ Abnormal findings ” (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance If findings are outside the normal and if the physician has ordered other tests to evaluate the condition or treatment, query the physician to ask whether the abnormal finding should be used
Advice given to a new coder is to begin to code a record by reading the discharge summary The discharge summary equals the synopsis of a book You should be able to determine the principal diagnosis ; however, documenting physicians may list a diagnosis that does not meet the requirements because they are not aware of the requirements Other places to look: Start at the beginning. The ER record will give you the patient ’ s chief complaint and will generally give the coder the admission diagnosis. The admitting diagnosis may be a symptom After exam there may be a working diagnosis The ER physician should have a working diagnosis or a sign/symptom for more workup to admit If not clear from the ER record, try admission orders for the reason for admission If no ER record, or it does not help, move on to the Admission History and Physical (H&P) Next, check progress notes, Op reports, labs, radiology, consults, and orders
Code from any documentation by a physician Physician = an individual qualified by education and legally authorized to practice medicine Other terms: attending, consulting, interns, and residents Check your medical staff bylaws: documentation by other healthcare providers (nurse practitioners or physician assistants) may be valid Medical students are not physicians
Confusion as to what exactly may be coded from a radiology or pathology report, as the authors of these reports are physicians: The coder cannot take information from these reports without attending confirmation. Additional details such as area of fracture, or location of mass, relating to confirmed diagnoses may be taken from x-ray or pathology reports. EXAMPLE: If the physician has already documented an ulnar fracture, the coder may pick up additional detail on the site of the fracture from this report. HOWEVER, if the physician has not documented the femur fracture, the coder could not use the information from the radiology report.
Each facility should have its own policies and procedures in regards to the query process Coding queries are an approved part of the official medical record Query forms should only seek clarification of information that is already present in the record Facilities have developed standardized query forms for repeated documentation issues Query forms should contain data elements to identify the patient Must have a place for physician to sign and date response Wording is important AHIMA suggests that the query: Be clearly and concisely written; Contain precise language; Present the facts from the medical record and identify why clarification is needed; Present the scenario and state a question that asks the physician to make a clinical interpretation of a given diagnosis or condition based on treatment, evaluation, monitoring and services provided; Be phrased such that the physician is allowed to specify the correct diagnosis. For more information: American Health Quality Association (AHQA)
Why query? Unclear or questionable diagnoses; Evidence of treatment but no diagnosis; Medication is being administered but there is no diagnosis documented to correspond with this treatment
Verbal queries should be documented at the time of discussion or immediately after and they should contain the same format as written queries and contain the same clinical indicators that would be in a written query. If the query is not maintained in the medical record, it should become part of the permanent health record. Guidelines allow assigning codes to most possible conditions the term is too broad to be used in the query format
All queries must be supported by pertinent clinical indicators. For multiple choice and yes/no queries, additional options such as “clinically undetermined” or “not clinically significant” are suggested.
These suggestions are considered “best practices.” Coders should always follow the facility policy.
It is unacceptable to lead a provider to document a particular response. AHIMA in the Practice Brief Guidelines for Achieving a Compliant Query Practice has provided examples of compliant/non-compliant queries. These can be found at http://journal.ahima.org/2013/02/01/physician-query-examples/
Facility policy will control where queries are maintained
CHAPTER HIGHLIGHTS: Go around the room and ask students to give examples of the topics covered: If no interest – ask the following: QUESTION: What are the various sections of a medical record? (Administrative, clinical, demographic, admission H&P, physician orders, progress notes, nursing notes, anesthesia forms, operative reports, consultations, labs, radiology, path, discharge summary) QUESTION: Why would the discharge summary be the first thing in the record? (Because it should list a summary of patient diagnosis and treatment and possibly the principal diagnosis and procedure) QUESTION: Define principal diagnosis. (The condition after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care) QUESTION: Yes or no: Each facility should have its own policies and procedures with regard to the query process. (Yes) QUESTION: Yes or no: Coding queries are not an approved part of the official medical record. (No, they are part of the approved medical record)