Health Records in Other SettingsAmbulatory Care Rehabilitation
Long Term Care Home Care
Mental Health
Hospice
Why There are Differences The type of setting
The type of services
The type of patients served
Differences External factors
JCAHO Other regulatory bodies that may accredit a
facility State and local laws Rules that apply to facilities that receive funding
from the federal government
Similarities All facilities should document to
Ensure continuity of care Justify reimbursement Protect the facility or the patient in legal
proceedings Contribute to research and education
Emergency Room Records Documentation is limited to information
about the patient’s presenting problem
Important to document: Instructions given to patient Patients presenting complaint Evaluation Assessment
Emergency Room Records
See list of standard information required, text book page 73
Ambulatory Care Many forms are similar to those used in
hospitals Unique to ambulatory care may be:
Problem list Medications list Patient history questionnaire
Usually the patient fills out a history form themselves. In the hospital the physician does this.
Ambulatory Surgery Records
Very similar to records in a hospital-based surgery department
Ambulatory Surgery Records Medicare requires
Patient ID History & Physical Preoperative studies Findings and techniques of the operation
including pathology reports
Ambulatory Surgery Records Medicare requirements, cont…
Allergies and abnormal drug reactions Record of anesthesia administered Informed consent to treatment Discharge diagnosis
Ambulatory Surgery Records Should also include documentation of:
The patient’s course in the recovery room
Routine follow-up phone call or visit
Long Term Care (LTC) The regulations that govern long term care
facilities have established strict documentation standards Most are governed by both federal and state
regulations Most do not participate in voluntary accreditation
processes
Long Term Care Records are based upon ongoing assessments
and reassessments of the patient’s needs RAPS – Resident Assessment Protocols
The health care team develops a plan of care for each patient and the plan is regularly updated
Long Term Care Resident Assessment Instrument (RAI) is the
format for the care plan that is required by federal regulations
The plan is reassessed on a quarterly and annual basis and whenever there is a significant change in patient’s condition
The RAI is a critical component of the health record
Long Term Care MDS – Minimum Data Set
Medicare form used to determine Medicare reimbursement
Many states also use it to determine Medicaid reimbursement
Accreditors or licensors use the information during the survey process
Long Term Care Centers for Medicare and Medicaid Services
(CMS, formerly HCFA) uses MDS data to compile information on demographics and quality indicators
Feedback is provided to each family
Long Term Care Unique to LTC is that most documentation is done
by nurses and other health care providers rather than physicians
Physician develops the plan of treatment
Physician visits patient on a 30-60 day schedule and reviews treatment plan and makes updates/orders as needed
Home Health Care (HHC) Huge growth in this area
Patient’s desire to be at home for as long as possible has fueled this industry
Cost savings as compared to residential facilities
Home Health Care Medicare regulations and accreditation
standards have established documentation requirements
Mandate periodic assessments Plan of Care is a central component of
documentation Plan of Care is established by the physician
ordering treatment
Home Health Care Plan of Care
Physician must renew plan every 60 days Updates can be made by telephone orders from
physician Physician visits in the home are not required Patients may be required to visit the physician
Home Health Care OASIS
Outcomes and Assessment Information Set Medicare form Standardized assessment form Foundation for the plan of care Basis for Medicare reimbursement Submitted electronically to CMS
Home Health Care Unique to home care is a service agreement
Details the type and frequency of services, the charge for the services, and the parties responsible for payment
Home Health Care Documentation depends on the services
ordered Each visit must be documented Challenge of maintaining records when
caregivers are not in a central location Some parts of the record may be kept in
patient’s home to allow for effective communication between caregivers
Home Health Care Record maintenance issues
How do documents get to main office? How often? Who tracks this?
Security issues Care providers driving from home to home with
confidential documentation in their car Electronic record would be ideal
Home Health Care
See list of other typical documentation, in text book page 78
Hospice Basic ID date Plan of Care and documentation of care given Palliative care
Keeping the patient comfortable and as pain free as possible
Care plan is reviewed every 30 days Federal regulations and accreditation
standards guide hospice documentation
Hospice Care continues even after death of patient
Follows the family through the bereavement process and can last as long as one year
Behavioral Health Care Mental Health Delivered in a variety of settings
Inpatient hospitals Outpatient clinics Rehabilitation programs Community mental health programs
Behavioral Health Care Documentation requirements differ in each
setting See the minimum documentation
requirements unique to the behavioral health setting established by JCAHO on page 79 of text book
Rehabilitation Services Health record documentation reflects the level
of care provided
CARF – Commission on Accreditation of Rehabilitation Facilities The accreditation body for rehabilitation facilities
CARF requires a record for each patient
Rehabilitation Services Evaluations and recertifications every 30-60
days Often have to be mailed to physician for signature
See documentation requirements on page 80 of text book
Job Preparation As long as you know “the basics” and can
transfer that knowledge to the different types of facilities, you will be able understand and adapt to the health information systems at different types of facilities
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