2. 3716 Highway 39 North
Meridian, MS 39301
601-482-7164
Kristy Certain, NHA
Previously known as Riley
Nursing Center
Long-Term Care &
Rehabilitation Services
80 Licensed Beds –
Currently 74 Patients
Medicare and Medicaid
Eligible
For-Profit Corporation by
LaVie Care Centers
Scott Bartes, CEO
LaVie’s Core Values
Team
Compassion
Quality Commitment
Service Excellence
Fun
3. Healthcare Services
24-Hour Skilled Nursing
Care
Comprehensive
Rehabilitation Services
Nutritional Services
IV Therapy
Pharmacy & Laboratory
Services
Radiology Services
Discharge Planning
Services
QMRP Services
Offsite Medical Services
Specialized Wound Care
Program
Post-Surgical Wound Care
Wounds Resulting from
Diabetes
Wounds Due to Poor
Circulation
Venous Stasis Ulcers
Pressure Ulcers
Non-healing Surgical or
Traumatic Wounds
5. The Oaks Healthcare Team
Medical Director
Four Staff Physicians/1
Nurse Practitioner
Director of Nursing
Registered Nurses
Licensed
Practical/Vocational
Nurses
Certified Nursing
Assistants
Rehabilitation Coordinator
Physical Therapists
Four Occupational
Therapists
Speech Therapists
Dietary Manager & 8 Aides
Registered Dietitian
Social Services Director
Psychiatric, Podiatry,
Dental & other Specialists
as needed
Health Information Staff
Billing & Reimbursement
Activity Director & 3 Aides
Laundry & Housekeeping
6. The Oaks Organizational Chart-Page 1
Nursing Home Administrator
Professional/Allied Health
Physicians Head Nurse/Nursing
Nurse
Practitioner
Charge Nurse
RNs, LPNs/LVNs
MDS
Coordinator
Education
Therapy
Physical,
Occupational,
Speech
7. The Oaks Organizational Chart-Page 2
Allied Health/Support Staff
Administrative
Health
Information
Admissions
Billing/Human
Resources
Support Staff
Social Services Dietary Recreation
8. Offsite Services Offered to The Oaks
Laboratory
Radiology
Pharmacology
Various Specialists
Dental
Psychiatric Services
Renal Dialysis Services
Hospice Services
9. Electronic Health Records Systems Utilized
American Healthtech®
Utilized by the majority of the staff in this
facility. The main page entities includes
reports, CMS, Setup, Custom,
Demographics and the following resident
documentation entities: basic
information, clinical information, status
changes, therapy, Part D Plans, billing and
after hours ADT.
Resource Systems: CareTracker®
Used for utilization of patient activities of
daily living skills (ADLs) and vital signs.
Resources Systems: MDS Director™
Used by the MDS coordinator as required
for facilities receiving federal funding.
LaVie Health Systems
Utilized by nursing and various therapies
in documenting information on residents.
10. Orientation to The Oaks/Daily Functions
I visited the facility a few days before my
practicum. I met with the nursing home
administrator Kristy Certain. I signed the
necessary contracts and privacy notices. I
was then introduced to the medical record
worker Lori Yoder. She gave me a tour of the
facility and introduced me to the staff. I
found the environment to be warm and
inviting. The 80-bed facility had a lobby,
dining area, smoking area, activity area,
resident dayroom, physical therapy area, two
residential wings and various offices. I
noticed that CareTracker ® systems were
located at the two wings and in the dining
area. TCO – 2,6, 7
There were also three sheds located at the
back of the facility. One for medical and
administrative records, another for
miscellaneous records/building items and
another for laundry duties. TCO -1
Collection of pink slips—physician telephone
orders written by nurses. This information is
inputted into the American Healthtech®
EHR systems. TCO 1, 8
Month’s end duties consists of physician
orders for the month is printed out, death
reports are sent to Vital Records by fax,
rollover orders are updated for the next
month. Examples of rollover orders are
Vitamin B12 shots which are fixed
dosages/times and Accu-Chek® monitoring
for diabetic patients. TCO 1, 4, 5
Daily meetings are held in the dining area.
Representatives of different staff are present.
The daily census report is read including the
count for Medicare, Medicaid, Private Pay,
Pending Medicaid, room changes, resident
information statuses & miscellaneous
hospitalizations, admissions, discharges,
transfers, and deaths. Also daily activities
and appointments are also discussed.
Excellent communication is observed. TCO 9
11. Observations & Hands-On Experiences
Health information data collection are obtained
from physician telephone orders,
admissions/discharge/transfer information,
resident charts, and medication administration
records (MARs). TCO 1, 2, 8
Legal matters—Power of Attorney, a copy is put in
the chart and copy in the medical record. The same
goes for the advance directive. TCO 1, 7
Lab reports are queried to nurses if necessary—BMP
everyday. Lab Requisitions are maintained by the
medical record personnel. TCO 2, 8
Older records are located in a locked shed outside of
the facility. Other facility records are also located
here. An offsite records facility is also utilized.
Filing system is in alphabetical order. I assisted in
filing and rearranging files in the new lateral shelf
cabinets. TCO 2
I went with my preceptor almost daily to do offsite
doctor rounds to collect signatures on orders and
documentation on residents. Also prescriptions are
picked up and faxed to the pharmacy. Copies of
faxed prescriptions are filed . TCO 2,
New admissions are created by using the –
chart health information program for medical
charts. TCO 1, 2, 8
Observed how a face sheet and clinical
information is created. Data entry of patient
information is derived from admissions
information (abstraction). Print three face
sheets for the following: resident chart,
podiatrist (comes every three weeks), and the
Master Patient/Patient Index Card (stored in
a large notebook) TCO 1, 2, 8
Chart creations consists of MARs-Face sheet,
Diagnosis sheet, physician orders, Treatment
sheets, Nursing—Diabetic Flow sheets-if
applicable. TBT, CXR, H&P are also in
chart. TCO 1, 2, 8
Three types of charts are created: Treatment
book, MARs, and Resident Chart. TCO 1, 2, 8
Observed the creation of lab requisition for
residents. TCO 1, 2, 8
12. Observations and Hands-On Experiences cont.
Admissions packets creation:
Admissions order
Immunization Record
Master signature log
Lift profile
Full Code notice
Pain Assessment sheet
TB Screening and Testing Record
Physician progress notes
Care plan
Release of responsibility for leave
of absences/passes
*Resident Information Sheet to be
used in the CareTracker® system.
TCO 1, 2, 3, 7, 8
Non-EHR sources used:
ICD-9-CM for Skilled Nursing
Facilities and Hospices, Volumes 1, 2,
& 3 (2010)
Care Management Review is done
once a week.
Patient changes such as weight,
bowel movements, behavior, etc.
Care review/care plan for
assessments:
Diabetics/insulin
Teeth
Infections
Hypertension
Code statuses
Medications
TCO 1, 4, 5, 8
13. Hands-On Experiences
Utilized reading physician
telephone orders and deciphered
medical terms. TCO 1, 2, 8
Data entry of new information on
the EHR. My preceptor walked
with me through the process.
TCO 1, 3, 8
Sorting and filing loose papers.
TCO 1
Utilized the electronic ICD-9-CM
codes and NDC code programs as
well. TCO 1, 2, 3, 8
Learned how to enter times/time
codes for drug administration and
appointments. TCO 1, 8
Input information into the
CareTracker system. TCO 1, 8
Learned how to do quantitative
analysis of charts by checking the
charts for physician signatures
and dates on doctor’s orders and
flagging the charts for signatures.
TCO 2
Also checked the charts to make
sure the residents’ name, medical
record number, physician’s name,
and room number are filled in on
various documentation on in the
chart. TCO 2
Filed documentation in chart that
is more than three months old
from current date. TCO 2
Filed resident medication records
in filing cabinet. TCO 2
14. A visit with the MDS Coordinator
The MDS Coordinator is a registered
nurse
Utilizes the Resource Systems MDS
Director program.
Keys in information from the resident
charts and the face sheet onto the MDS
program
Collects pain assessment information
and makes sure they are signed
Performs data entry of CareTracker
assessments
Assessment timetable
Admissions, 5-day, 14-day, 30-day, and
90-day
Timetable of MDS review
5-day—pays up to 10 days
14-day—pays up to 30 days
TCO 1, 2, 4, 5, 8
Care plans are done five days after
admission
MARs are also checked for medications
such as insulin, behavioral
medications, etc.
Protocol of Patient Assessment
Assessment/MDS
Decision Making
Care Area Assessment (CAA)
Care Plan Development
Care Plan Implementation
Evaluation
Resident Assessment Instrument (RAI)
for Nursing Homes is utilized
Three basic components
MDS v. 3.0
CAA-Care Area Assessment
RAI-Utilization Guidelines
TCO 1, 2, 3, 4, 5, 8
15. Concerns/Conclusion
Notes of Concern
Lack of staffing in medical records
department, only one medical record staff
and no workspace
Location of storage shed for older records
Medical records office is too small for
filing duties and chart preparation
Disaster preparedness for medical records
Interdisciplinary chart review should be
implemented with other healthcare
professionals
Location of policy and procedures should
be easily accessible
Conclusion
The practicum experience began with
meeting with the nursing home
administrator and the only medical
records staff. I observed the various
duties done in the health information
department. I was able to gain experience
working on the EHR and utilize skills in
medical terminology, health records
documentation and quantitative analysis.
I didn’t know that MDS and care plans
are done by RNs and I had a chance to
observe what they do. Attending
meetings gave insight on the happenings
at the facility. I also established a rapport
with the various staff at the facility. I also
learned what type of documentation
procedures are done by other staff
members. I enjoyed doing the
quantitative analysis at the nursing
station, which gave me a view how the
nursing staff utilize the CareTracker
system along with the EHRs specialized
for nurses well. In conclusion, there is
never a dull moment in processing health
information and it involves everyone.
16. Final Thoughts
My final thoughts on this practicum was a
memorable one. I am glad that I had finally
got a chance to work in the medical records
department at a skilled nursing facility. It
was definitely a difference as compared to
our studies which focused on the hospital and
physician offices. Working with someone
that was non-credentialed and less than two
years of experience in health information was
an eye opener but she knew how the
processes went. Plus the fact the she was the
only medical records staff working there. I
can imagine the pressure she goes through.
The filing system was a different because the
preceptor was alphabetizing in reverse
order—from the back to the front. When I
noted this in my class discussion, I
discovered that this is the way the military
does their filing system. I was able to meet
most of my TCOs but was disappointed that I
wasn’t able to observe the processes of
billing and admissions . TCO 3
I was able to get hands on experience on
abstracting information to the EHRs, filing
loose papers and records, and doing
quantitative analysis on residents’ charts. I
along with other staff from different
professions as well. I felt like I was a regular
employee while I was there. It felt good to be
complimented that I was a hard worker and
stayed on task on whatever duties was given
to me. I also enjoyed interacting with my
classmates during the discussions and the
experiences they were going through.
Working in the health information field is no
easy feat but I respect the profession to the
fullest extent. I didn’t realize there is so
much to the medical record and to the
medical records staff. This is a challenging
profession but provides the link between the
patient and provider when it comes to health
information documentation.
