Title: Documentation in Acute Care
1Documentation in Acute Care
- Chapter 5
- Accreditation and Regulatory Requirements for
Acute Care Documentation
2Mandatory Requirements for Acute Care
- Federal statutes and regulations
- State statues and regulations
- County and municipal ordinances and codes
- State and federal judicial decisions
3Legal 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
4Legal 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.
5Voluntary Requirements for Acute Care
- Accreditation organizations JCAHO, CARF, etc
- Professional certification organizations AHIMA,
AMA, etc - Standards development organizations ASTM, HL7,
etc
6General 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
7Health 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.
8Legal requests for records
- Subpoena
- Subpoena duces tecum
- Court order
9Form 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
10Ownership 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
11Other Health Record Control Issues
- Release and disclosure
- Redisclosure
- Retention/destruction
12Release 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.
13Redisclosure
- 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.
14Retention 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
15Destruction 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
16Certificate 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
17State 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
18Medicare 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.
19Medicaid 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.
20Medicare 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.
21Medicare 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.
22Medicare 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
23Deemed 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.
24Health 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
25HIPAA 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
26HIPAA 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.
27HIPAA 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.
28HIPAA 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.
29Requirements 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.
30Requirements 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.
31Requirements 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.
32Minimum necessary standard
- Requires the healthcare facility to identify
individuals or classes of individuals in its
workforce who need access to protected health
information.
33Authorizations 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
34Authorizations 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
35Authorization 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
36HIPAA 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.
37Physical 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
38Technical Security Mechanisms and Procedures
- Access control technology
- Data authentication
- Audit trails
- Encryption technology
39HIPAA 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
40HIPAA 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
41HIPAA 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
42Special 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
43Psychiatric 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
44Substance 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.
45Records 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
46Confidentiality Issues related to HIV/AIDS
- Consent for testing
- General information on testing
- Reporting of test results
47Records that contain Genetic Information
- Protected under state health record regulations
- HIPAA addresses health insurance discrimination
based on genetic information
48Accreditation 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
49Joint 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.
50Organizations 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
51JCAHOs 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.
52Elements 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
53Scoring method applied to EPs
- 0 Insufficient compliance
- 1 Partial compliance
- 2 Satisfactory compliance
- 3 Not applicable
54JCAHOs 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
55JCAHO 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
56JCAHO 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.
57JCAHO 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.
58PFP 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
59Priority Focus Areas (PFAs)
- Processes, systems and structures that can have a
substantial effect on patient care services.
60JCAHO 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
61JCAHO 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
62Tracer 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.
63JCAHO Accreditation Decisions
- Accredited
- Provisional accreditation
- Conditional accreditation
- Preliminary denial of accreditation
- Denial of accreditation
- Preliminary accreditation
64American 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)
65Healthcare 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
66Commission 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
67CARF Survey Process
- Scheduled in advance
- Opening conference
- Document review
- Interviews with program staff and patients
- Exit interview with organizations leaders
68CARF 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
69Other 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.
70Corporate 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.
71Credentialing 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
72Credentialing 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
73Credentialing 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)
74Privileging 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.
75Risk 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.
76Reportable 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.
77Health 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
78Standards 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)
79Health 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
80Health 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
81Health Informatics Standards organizations
- Health Level Seven (HL7)
- EHR Collaborative
- American Society for Testing and Materials (ASTM)
- SNOMED Clinical Terms (SNOMED CT)
82Internal 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.
83General categories of hospital policies
- Administration, including HIM
- Medical staff
- Nursing services
- Human resources
- Safety
- Environment of care