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Documentation in Acute Care

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Title: Documentation in Acute Care


1
Documentation in Acute Care
  • Chapter 5
  • Accreditation and Regulatory Requirements for
    Acute Care Documentation

2
Mandatory Requirements for Acute Care
  • Federal statutes and regulations
  • State statues and regulations
  • County and municipal ordinances and codes
  • State and federal judicial decisions

3
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
    states governor
  • Regulation a rule established by ad
    administrative agency of government

4
Legal definitions contd
  • Municipal ordinance/code a rule established by
    a local government
  • Judicial decision a ruling handed down by a
    court to settle a legal dispute.

5
Voluntary Requirements for Acute Care
  • Accreditation organizations JCAHO, CARF, etc
  • Professional certification organizations AHIMA,
    AMA, etc
  • Standards development organizations ASTM, HL7,
    etc

6
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

7
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.

8
Legal requests for records
  • Subpoena
  • Subpoena duces tecum
  • Court order

9
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

10
Ownership and Control of Health Records
  • Generally considered the property of the hospital
    or healthcare provider that maintains the
    records.
  • Must remain under the facilitys 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

11
Other Health Record Control Issues
  • Release and disclosure
  • Redisclosure
  • Retention/destruction

12
Release and Disclosure of Confidential Health
Records
  • Health Insurance Portability and Accountability
    Act (HIPAA)
  • The patients 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.

13
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.

14
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

15
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

16
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

17
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

18
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.

19
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.

20
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.

21
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.

22
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

23
Deemed Status
  • Granted by Medicare to hospitals that are
    accredited by JCAHO or AOAs accreditation
    programs.
  • CMS requires that approximately 10 of the
    hospitals with deemed status undergo a Medicare
    validation survey.

24
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

25
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

26
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
    patients treatment.
  • Can disclose patient information to another
    healthcare provider or covered organization for
    purposes related to reimbursement for services
    provided to the patient.

27
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.

28
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.

29
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.

30
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
    patients authorization.

31
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.

32
Minimum necessary standard
  • Requires the healthcare facility to identify
    individuals or classes of individuals in its
    workforce who need access to protected health
    information.

33
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 individuals right to revoke
    the authorization

34
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

35
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

36
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.

37
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

38
Technical Security Mechanisms and Procedures
  • Access control technology
  • Data authentication
  • Audit trails
  • Encryption technology

39
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

40
HIPAA Administrative Requirements contd
  • 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

41
HIPAA Administrative Requirements contd
  • 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

42
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

43
Psychiatric Care and Psychotherapy Records
  • Psychiatric records include two separate records
  • Official record that documents the patients
    care and treatment
  • Personal record which documents the clinicians
    experience and conversations with the patient
  • Release of psychotherapy notes requires a
    specific authorization

44
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.

45
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

46
Confidentiality Issues related to HIV/AIDS
  • Consent for testing
  • General information on testing
  • Reporting of test results

47
Records that contain Genetic Information
  • Protected under state health record regulations
  • HIPAA addresses health insurance discrimination
    based on genetic information

48
Accreditation Requirements for Acute Care
Hospitals
  • Accreditation a systematic quality review
    process that evaluates the healthcare facilitys
    performance against preestablished written
    criteria, or standards.
  • JACHO, AOA, CARF, AAAHC, NCQA

49
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.

50
Organizations eligible of JCAHO accreditation
  • Acute care hospitals
  • Critical access hospitals
  • Childrens hospitals
  • Psychiatric hospitals
  • Rehabilitation hospitals
  • Ambulatory care organizations
  • Behavioral health organizations
  • Home care agencies
  • Long-term for skilled nursing facilities
  • Healthcare networks
  • Clinical laboratories

51
JCAHOs 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.

52
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

53
Scoring method applied to EPs
  • 0 Insufficient compliance
  • 1 Partial compliance
  • 2 Satisfactory compliance
  • 3 Not applicable

54
JCAHOs Management of Information
  • Identification of the hospitals information
    needs
  • Structure of the hospitals 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

55
JCAHO Sentinel Event Policy
  • An unexpected occurrence involving death or
    serious physical or psychological injury, or the
    risk thereof
  • Hospitals need processes in place to identify
    and manage sentinel events

56
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
    hospitals representative about a plan of action
    for shortcomings identified in the PPR.

57
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.

58
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

59
Priority Focus Areas (PFAs)
  • Processes, systems and structures that can have a
    substantial effect on patient care services.

60
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

61
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

62
Tracer Methodology
  • An evaluation that follows (traces) the hospital
    experiences of specific patients.
  • Surveyors are able to evaluate ho well the
    hospitals processes and departments work with
    each other.
  • Surveyors interview the physicians and staff
    involved in each patients care as well as the
    patients themselves when possible.

63
JCAHO Accreditation Decisions
  • Accredited
  • Provisional accreditation
  • Conditional accreditation
  • Preliminary denial of accreditation
  • Denial of accreditation
  • Preliminary accreditation

64
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)

65
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

66
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

67
CARF Survey Process
  • Scheduled in advance
  • Opening conference
  • Document review
  • Interviews with program staff and patients
  • Exit interview with organizations leaders

68
CARF Accreditation Decision Process
  • Based on an objective assessment of the
    facilitys performance compared to CARF
    standards.
  • Standards Conformance Rating System
  • 0 Nonconformance
  • 1 Partial conformance
  • 2 Conformance
  • 3 Exemplary conformance

69
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.

70
Corporate Negligence
  • Legal doctrine established by a judicial decision
    in the Darling v. Charleston Community Hospital
    in 1965.
  • The hospitals 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 patients treatment by a
    personal physician.

71
Credentialing Process
  • Verification of the applicants undergraduate,
    medical, and postdoctoral education
  • Verification of the applicants residency and
    fellowship training as well as continuing medical
    education
  • Past and current medical staff appointments at
    other facilities

72
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
    applicants professional peers

73
Credentialing Process
  • Information on the applicants health status
  • Past and current liability status
  • Inquiries to two national databases
  • National Practitioner Data Bank (NPDB)
  • Healthcare Integrity and Protection Data Bank
    (HIPDB)

74
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.

75
Risk Management
  • The process of overseeing the hospitals internal
    medical, legal, and administrative operations
    with the goal of minimizing the hospitals
    exposure to liability.
  • Liability the legal responsibility to
    compensate individuals for injuries and losses
    sustained as the result of negligence.

76
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.

77
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

78
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)

79
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

80
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

81
Health Informatics Standards organizations
  • Health Level Seven (HL7)
  • EHR Collaborative
  • American Society for Testing and Materials (ASTM)
  • SNOMED Clinical Terms (SNOMED CT)

82
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.

83
General categories of hospital policies
  • Administration, including HIM
  • Medical staff
  • Nursing services
  • Human resources
  • Safety
  • Environment of care
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