NORTH AMERICAN –Medical Records – 2011 Status to Quality DocumentationRHONDA ANDERSON, RHIA, President, AHIS

In coordination with Marivic Perez, R.N.

Presented By

RHONDA ANDERSON, RHIAAnderson Health Information Systems, Inc.

940 W. 17th St., Santa Ana, California, 92706 Phone 714-558-3887

Email: rhonda@ahis.net, trisha@ahis.net, lizeth@ahis.net

IN COORDINATION WITH

NORTH AMERICAN HEALTH CARE 2

Objectives

• PARTICIPANTS WILL:• Follow-up on prior requirements for Quality

Documentation• Identify the schedule for audits and related findings

in coordination with other audit• Identify all the audits and if there is duplication how

to manage that toward accurate quality documentation.• Identify training and other needs• Identify new approaches and also what is 100%

audit 3

Objectives -2

• PARTICIPANTS WILL (cont.)• Peer Review – what is it?• Clinical Documentation Improvement – defined and

how can we use to reduce ‘ole fashion’ audits• Findings and action plans from workshop reviews.• Quality Assurance – what is you role and how are

you carrying it out?• MDS Filing – identify questions and solutions• Solutions to your workshop “best practices”

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Audit Schedule

• Identify the required audits• Identify the period audits• What is your coverage and cross-training like?• What is your follow up system• Is it effective.

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Healthcare (CDI) Consumer & Agency is Unique• In their services• Staff skill set• Combination of medical conditions• Services

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North American Facilities

• Number of admissions• Complexity of the healthcare conditions• Proactive clinical review process

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Focus of Most CDI Programs

• Improving the quality of clinical documentation regardless of its impact on revenue or care• Facilitating an accurate representation of

healthcare inservices• Through complete & accurate

reporting/documentation of care• Diagnoses to support that care & clinical procedures• Facilities communication

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CDI Processes Proactive Review of Documentation• Documentation is reviewed near when it

happens• There is a facilitated process to clarify the

services and documentation• Need to capture quality documentation near the

point of care to support those services.• Challenge is obtaining that quality documentation• Collecting some standardized data to compare the

quality documentation• Taking action on those findings

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Record Review Historically

• Data collection occurred after the resident discharged• Retroactive audit processes• Monitoring proactive Clinical Documentation

Improvement

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CDI Process

• Proactively (not post or after the fact audit the next day or an “auditor” coming in• Real time activity close enough to the situation

that clarification/completion of documentation

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Examples of Suggestions for Most High-Risk Areas• Self actualization• Self checking• Cross review by the caregivers• Medical Records involvement more proactive

or near the activity, i.e., change of condition review more often during the day, not wait until the next morning

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CDI

• Downside to this proactive involvement by nursing and cross-checking themselves is “we do not have time”

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Medical Records

• Utilize monitoring tools• How and when these monitoring tools are

used is the challenge

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Methods of Implementing a CDI Process• Changing the method of when the monitoring

would be carried out• From post audit to near real time

• Add some admission clinical criteria for review, i.e. for Medicare coverage by diagnosis/covered type• Change of condition review to be carried out

more frequently each day not during that day, i.e., a.m., p.m. before end of shift and late in the evening

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Methods -2

• Qualitative Treatment audit carried out• Immediately following Treatment rounds each

week• By the RN Supervisor and/or HIM/Record staff

immediately• For example, review the ‘qualitative treatment criteria’

• Discharge, if resident discharge to home• Post discharge plan of care completed• Reviewed by another nurse• Complete and meets requirements

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Methods -3

• Discharge, if resident discharge to home (cont.)• Notification to HIM/Records Department to review

record before discharge• Send information to physician along with discharge

telephone order or sign while in-house

• All discharges

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Method -4

• Current NAHC processes that changed into a CDI, i.e., change of condition, admission, discharge, qualitative treatment medication/treatment documentation, behavior drugs, Medicare coverage review, weekly licensed nursing notes.• Tracking certs/recerts and follow-up

physician, physician’s visits• 100% audit – Review examples

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Re-Evaluate the QA/I Committee Activities• Utilize the systems that are already in the

AHIS HIM/Record Manual• Review the ‘standup’ process

Quality Assessment

• Established a Quality Assessment/Assurance Committee that:• Is a standing committee of the facility;• Identifies and addresses quality issues;• Provides points of accountability for ensuring

quality of care and quality of life;• Coordinates the qualitative evaluations of facility

systems;• Establishes assessment and improvement priorities

for resident care and services;20

Quality Assessment -2

• The facility has an established Quality Assessment/Assurance Committee that:• Sets expected outcomes for resident care, services,

safety, including applicable informed consents for psychotherapeutic drugs, restraints and prolonged use of devices that may lead to he inability to gain use of a normal body function and related administrative services;

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Quality Assessment -3

• Established a Quality Assessment/Assurance Committee that:• Monitors and evaluates quality practices, safety and

outcomes utilizing the facility roster/matrix, investigative protocols and the facility Quality Indicator/Quality Measure Reports MDS 3.0 and other clinical statistical reports available in the computer system/, and results from customer satisfaction surveys;• Collects and analyzes data, practices that cause

negative outcomes, enhances quality of care, life and service;

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Quality Assessment -4

• Established a Quality Assessment/Assurance Committee that:• Communicates the results of quality assessment/

improvement • Develops and implements plans of action to correct

identified quality deficiencies and care processes• Keeps systems functioning, including maintenance

of correct practice standards;• Establishes a method of reporting to the Governing

Body;23

Quality Assessment -5

• Established a Quality Assessment/Assurance Committee that:• Is responsible for those functions previously designated to

the [ ] pharmacy infection control and the [ ] utilization review committee.

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Quality Assessment -2

• Evaluation, communications and implementation re: CMS State Operations Manual and other CMS updates and California Department of Public Health – All Facility Letters (AFL) as applicable• Include informed consent for

psychoactive/antipsychotic/psychotherapeutic drugs, restraints and prolonged use of devices.

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Quality Assessment -2

• Review shall include but not be limited to assessment:• Of effectiveness of the monitoring and evaluation

process;• Of performed quality assurance activities versus the

quality assessment/assurance plan;• Of communication of quality assessment

information;• To determine if resident care has improved.

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Quality Improvement Plan – By Month

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Admission – 7/14/21/30 Day Monitor• Key Issues• Consents to Tx / Rights signed/dated by

resident/legal representative• H&P completed or updated / Informed consent /

Rehab. Potential within 72 hours

• Behaviors Drugs• Include diagnosis, specific behavior manifestation• Behavior count initiated• Notification of interested family member of

antipsychotic medication orders if resident consents

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Admission – 7/14/21/30 Day Monitor -2

• Restraints• Informed consent obtained for restraint orders

(physical)• Informed consent

• Devices• Informed consent

SBAR Documentation Forms

• Refer to H.O. #4

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SBAR Change of Condition (COC)

• Review the communication book to determine• Change in condition is identified• Follow up that is carried out

• Use COC Monitor daily to review SBAR (C of C) documentation• Take to standup q day• Quantitative and qualitative review• Take notes re condition, observations, nursing

action, pain scale if applicable

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SBAR COC -2

• Review SBAR = complete, date, time, description of condition, observations (also check the nurses’ notes for consistency in documentation)• Check for:• Follow up note• Timely notification to MD, resident, family• Informed consent, if chemical/physical restraint is

applicable• Timely notification to Pharmacy• Pharmacy order book for new/change

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SBAR COC -3

• Check for:• See if the medication was ordered from the

Pharmacy or a new label requirement

• New order carried out – on PO form, order completed; Dx added• New order, PO = Med/Tx sheet, laboratory/x-ray

• Condition on Care Plan• Date, shift nurse who documented• Identify if a remonitor is due

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Informed Consent – Psychotherapeutic Meds & Devices• The resident has a right to• Make decisions with regards to his/her medical

condition• Accept/refuse the proposed treatment• Free from any physical/chemical restraint imposed• Receive information and consent to the use of

physical/chemical restraints and prolonged use of devices

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Informed Consent -2

• Attending physician shall be responsible for:• Obtaining informed consent• Prior to the first use of a physical/chemical restraint• ON ADMISSION if had a restraint or chemical

restraint/psychotherapeutic drug prior to admission• When a chemical restraint / psychotherapeutic drug

dosage is increased, informed consent is needed only if the increase falls outside of the dosage range covered by the previous consent. (Informed consent may be obtained for a specific dosage range. Refer to the specifics within the Pharmacy manual also).

• Verification of informed consent• Determine the resident’s decision making capacity

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Informed Consent -3

• Attending Physician responsible (cont.)• Seek consent of capable residents• Notify interested family member

• Use of a device is anticipated to be prolonged which might result in the loss of bodily function. Most common devices include: urinary catheters, nasogastric tube, gastrostomy tube

• Facility’s responsibilities:• Documenting verification of informed consent• Assessment of appropriateness of medication or

device and determination of risks/benefits

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Informed Consent -4

• Treatment may be initiated without informed consent if:• Documentation in the record of an emergency

• “New” physicians will be advised of the requirements

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Resident’s Capacity Determination Guidelines• Physician shall make a determination of

resident’s capacity & document his/her ability for decision-making• Not capable of his/her own decision-making• Surrogate decision-maker shall receive the

same information and have the same rights as the resident• When a conservator provides informed consent,

conservatorship papers must be on file• When no conservator, designated representative

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Informed Consent

• Facility staffs• Verify that the resident’s record contains

documentation that the resident has given informed consent• Physical/chemical restraints / psychotherapeutic drugs• Prolonged use of a device

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Pressure Sore / Ulcer / Skin Conditions Monitor• Physician’s orders for each site• Review the skin report for the following items• Date, • Location site• Stage• Size• Depth• Exudate/drainage• Odor• Comments/progress or lack of progress• Nurse

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Pressure Sore / Ulcer / Skin Conditions Monitor -2

• Lab • If there is draining, check to see if a lab was ordered• If so, was there follow up? Comments?

• Family/Doctor Notified – Check for the notifications by nursing to the physician & family. • Usually in the nurses’ notes or weekly skin report

• Dietary • progress note that describes the skin condition• intake and addresses recommendations or none

depending on their clinical decision-making

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Pressure Sore / Ulcer / Skin Conditions Monitor -3

• CP current – review the CP to see if the condition on the Pressure Sore/Ulcer/Skin Conditions monitor. Discontinued when healed.• Care Plan – check:• To be sure there is a separate condition on the care

plan for each skin treatment• The intervention for preventive equipment,

observation of related conditions

• Check the Skin Report, Tx Sheets, CP and Weekly licensed nursing notes

Sample Review – Data Collection - Discuss

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Sample Review – Data Collection – Discuss -2

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Purpose – MDS 3.015 Months Retention of the MDS• Federal regulatory requirement at 42 CFR

483.20(d) requires nursing homes to maintain all resident assessments completed within the previous 15 months in the resident’s active clinical record.

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Policy – MDS 3.015 Months Retention of the MDS• Maintain 15 months of MDS• Be available to the • Interdisciplinary team, • Other key staffs,• Surveyors, CMS and other agencies,• Administrative uses

• Store all MDS assessments within the previous 15 months• Separate binders at each station / centralized

location• Available to all staff who need the MDS

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Procedure – MDS 3.015 Months Retention of the MDS• Resident is discharged return anticipated• Returns to the facility within 30 days• Copy the previous RAI and transfer that copy to the

new record• Does not return after 30 days, do not copy the

previous RAI to the new record

• Resident returns to the facility after a long break in care (e.g., 15 months or longer)• Review the older record to familiarize

themselves with the resident history and care – Do not need to copy previous RAI

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Procedure – MDS 3.015 Months Retention of the MDS -2

• Printed MDS to be filed is marked as “COPY”• Most current MDS Assessment (OBRA or PPS)

will be in the active charge• Previous MDS assessment will be filed in

binder at the nurse’s station up to 15 months of MDS• Slip sheet will be placed in the active record

indicating the location of the forms (e.g., “MDS Documents can be found in the alphabetically or numerically arrange MDS binders at the nursing station

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Use of Electronic Signatures for MDS• Purpose –• Ensure proper security measures are implemented

to maintain the integrity & privacy of the record per RAI

• Policy• Utilize electronic signatures for MDS (Minimum

Data Set)• Ensure proper security measures

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Use of Electronic Signatures for MDS -2

• Procedure• Employees should complete the form certifying the

use of own computer security• Signature is a result of individual’s unique

password• Electronic signature must only be used by the

person whose signature it represents

Best Practices!

• Let’s discuss…

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Thank You for Attending!

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