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