Project Presentation - Assignment Essays

Health Information Management Technology:
An Applied Approach,
Sixth Edition

Chapter 4: Health Record Content and

Documentation

ahima.org

Documentation

Recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregivers

Allows for the telling and retelling of events

Impact of Poor Documentation
Poor outcomes
Issues with patient care
Issues with the accuracy of diagnosis and procedure codes
Errors on healthcare claim

Describes those principles, codes, beliefs, guidelines, and regulations that guide healthcare documentation.
Dictates how healthcare providers should document the treatment and services within the health record.
Documentation Standards

Standard
Set of principles, codes, beliefs, guidelines, and regulations that have been vetted and agreed upon by an individual or a group of individuals.

Documentation Standard
Standard that controls health record documentation

EHRs and paper-based health records typically have the same basic documentation standards
Templates
Documentation Standards and EHRs

Standards
Documentation standards have grown in complexity and detail over time
Focus on
Patient care quality
Appropriate reimbursement
Prevention of fraud and abuse

Standards
Documentation standards vary upon the type of health record
Multiple sources of documentation standards:
Insurance company or payers
Government regulatory agencies
Licensing boards
Accrediting bodies
Facility policies and procedures
Medical staff bylaws

Goals of Documentation Standards
Ensure complete health record and accurately reflects the treatment provided to the patient
Drive appropriate reimbursement through accurate code capture

Medical Staff Bylaws
Standards governing the practice of medical staff members
Voted on by the organized medical staff and the medical staff executive committee
Approved by the healthcare organization’s board of directors
Used to enforce quality of care

Required by
Licensure organizations
Accreditation organization
Federal and state regulatory agencies
Each organization mandates content
Medical staff bylaws will vary slightly from one organization to another

Medical Staff Bylaws

Medical Staff
Physicians and nonphysician providers who have privileges to practice medicine at a particular healthcare organization
May or may not be employed by the healthcare organization
Medical staff are subject to the medical staff bylaws

Medical Staff Privileges
Specific services and procedures that the medical staff member is deemed qualified to perform, at a particular healthcare provider organization

Accreditation
A voluntary process
Periodical evaluation against preestablished written criteria
Healthcare organizations measure their own compliance with standards
Enhances the reputation of the organization in the eyes of the patient
Differs by the type of program or service

Accreditation
Healthcare organizations that are accredited by an approved accreditation organization are exempt from routine state survey agencies

Accreditation Organization
Must go through its own CMS review to obtain deemed status
Evaluates healthcare organizations for compliance with CoPs and CFCs

Joint Commission
Accredits wide variety of healthcare organizations
Continuously updates survey processes
Surveys clinical and operational components
Provides education to healthcare organizations related to compliance

Joint Commission
Provides accreditation for:
Ambulatory healthcare
Behavioral health
Critical access hospital
Homecare
Hospital
Laboratory
Nursing care centers
Physician offices
Office-based surgery centers

Other Accreditation Organizations
Healthcare Facilities Accreditation Program
Commission on Accreditation of Rehabilitation Facilities
Accreditation Association for Ambulatory Healthcare

State Statutes
Legislation written and approved by a state legislature and then signed into law by the state’s governor
Addresses the documentation requirements for specific types of health records

Legal Health Record
Documents and data elements that a healthcare provider may include in response to legally permissible requests for patient information
Content varies from provider organization to another

Legal Health Record
Policies and procedures should be established to defining legal health record

General Documentation Guidelines
Apply to all categories of health records
Every healthcare organization should have policies
Organized systematically to facilitate data retrieval and compilation

General Documentation Guidelines
Only individuals authorized by the organization’s policies should be allowed to enter documentation in the health record.
Organizational policy or medical staff rules and regulations should specify who may receive and transcribe verbal physician’s orders.

General Documentation Guidelines
Health record entries should be documented at the time the services they describe are rendered.
Authors of entries should be clearly identified in the record.
Only abbreviations and symbols approved by the organization or medical staff rules and regulations should be used in the health record.

General Documentation Guidelines
All entries in the health record should be permanent.
Any corrections or information added to the record by the patient should be inserted as an addendum
No changes should be made in the original entries in the record
Information added to the health record by the patient should be clearly identified as an addendum

CMS Documentation Requirements
Entries must be
Legible
Complete
Dated and timed
Author identified
Authenticated in written or electronic form

Authentication
Identifying the source of health record entries
Written signature
Initials
Electronic signature
CMS requires controls to prevent any changes from being made to the health record after the entries have been authenticated

Auto-Authentication
When a physician or other care provider authenticates an entry without reviewing

Documentation by Setting
Health record information consists of two types regardless of setting
Clinical
Administrative

Documentation by Setting
Must have health record for each person
Content varies by setting
Contains clinical and administrative data

Inpatient Health Record
Patient stays overnight
Medical or surgical
Most complex health record

Inpatient Health Record—Clinical
Medical history
Current condition
Past medical history
Personal history
Family history
Chief complaint

Inpatient Health Record—Clinical
Physical exam
Physician assessment
Diagnostic and therapeutic procedure order
Physician order
Standing order

Inpatient Health Record—Clinical
Clinical observation
Progress note
Integrated health record
Summary statement (death)
Care plan

Inpatient Health Record—Clinical
Autopsy report
Vital signs
Flow charts
Diagnostic and therapeutic procedure reports
Lab, pathology, and radiology and other tests/treatments

Inpatient Health Record—Clinical
Anesthesia report
Operative report
Recover room report
Pathology report
Consultation report

Inpatient Health Record—Clinical
Discharge summary
Overview of encounter
Not required for hospitalization less than 48 hours, uncomplicated delivery or newborn
Patient instructions
Transfer records

Inpatient Health Record—Administrative
Patient registration
Demographics

Special Health Records
Some health records have unique requirements because of the specialized services provided

Obstetric and Newborn Health Record
Obstetric
Prenatal
Labor and delivery
Newborn
APGAR

Ambulatory Health Record – General
Demographics
Problem list

Ambulatory Surgery Record
Similar to inpatient surgical health record
Follow-up post surgery

Ancillary Departments
Tests and procedures

Physician Office Record
Preventive care
Minor illnesses and injuries

Long-Term Care
Ongoing assessments
Care plan
Resident Assessment instrument
Minimum Data Set for Long-Term Care

Rehabilitation
Minimum Data Set, Version 3 (MDS 3.0) Resident Assessment Instrument
5-Day Assessment (mandatory)
Interim Payment Assessment (optional)
Discharge Assessment (mandatory)

Behavioral Health
Includes similar content
Family and caregiver input is documented

Home Health
Treatment plan
Health assessment
Problem list
Treatment goals
Interventions and outcomes

Federal and State Initiatives on Documentation
Trends are to focus on
Quality of care provided
Value-based care
Reimbursement provide incentives for quality of care
MACRA
Core Measures

Paper Health Record—Format
Source-oriented health record
Universal chart order
Integrated health record
Problem-orientated medical record
Subjective, Objective, Assessment, Plan (SOAP)

Electronic Health Record
Point-of-care documentation
Documentation captured electronically

Web-Based Document Imaging
Capture, digitize, integrate, store, and retrieve paper-based health record documentation
Organizes and assembles the paper-based health record documentation, and controls the versioning, access, and search capabilities of the documentation

Role of Healthcare Professionals in Documentation
Physicians
Document appropriately so that quality care can be rendered and that appropriate reimbursement can occur

Role of Healthcare Professionals in Documentation
Nurses
Documentation varies by licensing and regulatory requirements, setting, and internal policy and procedures

Role of Healthcare Professionals in Documentation
Allied Health Professionals
Many follow treatment plan developed by the patient’s physician or a therapist or technologist
Documents treatment and patient’s response

HIM and Documentation
Plays vital and different roles in the overall governance of health record information
Manages many aspects of the health record and its content
Used in coding, billing, and other HIM functions

HIM Roles
Clinical documentation integrity coordinator
Analyst

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Health Information Management Technology:
An Applied Approach,
Sixth Edition

Chapter 5: Clinical Terminologies, Classifications, and Code Systems

ahima.org

Definitions

Vocabulary/terminology: A set of terms specific to a domain

Nomenclature: A system of names that follows preestablished conventions

Classification: A mono-hierarchical method of organizing related terms together

Definitions
Code: An identifier
Code set: An accumulation of numeric or alphanumeric codes
Code system: An accumulation of terms and codes for exchanging or storing information

Definitions
Clinical Terminology: A set of standardized terms and codes used in the healthcare industry to encode clinical data

History and Importance
Name and arrange medical content
Historically to identify causes of death
Expanded to uses for patient care, measuring patient outcomes, research and claim submission for reimbursement

Expanded Uses and Data Capture
Claims data
Surface clinical content
EHR data
Detailed clinical content

Data Capture
Details are key to use: granular
Clinical terminologies
Code systems
Combination of data is sufficient: aggregate
Classifications
Code systems

Primary and Secondary Data Use
Primary use: granular
Example—clinical decision support
Secondary use: aggregate
Example—billing and payment

Clinical Terminologies, Classifications, and Code Systems
Selection of a standard for reporting
Primarily regulation driven
Content standards for representing electronic health information
Interoperability building block

Clinical Terminologies
Form the basis for coded data
Provide the data structure
Semantic interoperability
Health information exchange

Clinical Terminologies
Reference terminologies
Provide common semantics
Supports meaning-based retrieval
Example
SNOMED CT

SNOMED CT
Clinical terminology used for documentation and reporting
No book of codes and no assignment by a coding professional
Implemented in software applications
Granular level of clinical data capture

SNOMED CT (continued)
Purpose is to standardize clinical phrases
Used for sharing of clinical information
Standard for certified EHR systems
Structure
Concepts
Descriptions
Relationships

SNOMED CT (continued)
SNOMED CT identifier
Unique integer
Includes
Item identifier
Partition identifier
Check-digit
Namespace identifier when component originates in an extension
Nonsemantic

SNOMED CT (continued)
Concepts
Concept definition
Sufficiently defined
Partially defined (primitive)

SNOMED CT (continued)
Descriptions
Types
Fully specified name
Synonym
Preferred term

SNOMED CT (continued)
Relationships
Connection between a source and destination concept
Form the polyhierarchical structure of SNOMED CT
Is a relationship type

Current Procedural Terminology (CPT)
Nomenclature used for reporting procedures
Print, e-book, and in software applications
Assignment by a professional coder
Standard for certified EHR systems

CPT (continued)
Provides uniform language for services and procedures
Reports services and procedures on healthcare claims
Excludes inpatient claims
Structure
Codes, descriptions and guidelines
Category I, Category II, and Category III
Modifiers

Nursing Terminologies
Terminology used to report nursing care
Multiple terminologies available
Content, structure, and purpose varies
Examples
Nursing Interventions Classification (NIC)
Interventions
Nursing Outcomes Classification (NOC)
Outcomes

Classifications
Key to secondary data use
Aggregate clinical data
Healthcare statistics
Determine payment
Monitor public health
Improve financial performance

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
Developed and maintained by National Center for Health Statistics
ICD-10 Coordination and Maintenance (C & M) Committee
Updated in October and when necessary, April
Print, online, and in software applications

ICD-10-CM
Assignment by a professional coder
Used to report diagnoses on healthcare claims
Structure
3–7 characters

ICD-10 Procedure Coding System (ICD-10-PCS)
Created by 3M Health Information Systems
Maintained by Centers for Medicare and Medicaid Services
Reports procedures for inpatient claims
Updated in October and when necessary, April
Print, online, and in software applications
Assignment by a professional coder

ICD-10-PCS
7-character code
Sections
Medical and surgical procedures
Medical and surgical-related procedures
Ancillary procedures
Tables, index, and definitions

ICD-11
Foundation component
Linearization
ICD-11-MMS
Collaborative and open development and maintenance process
Development version continuously updated
Annual official release

ICD-11
Reflects scientific and medical advances
Can be integrated with electronic health applications
Easy to implement
Accessible and easy to use
Improved links to terminologies and derived and related classifications

ICD-11
New content
Chinese medicine disorders and patterns
Supplementary section for functioning assessment
New chapters
Sleep-wake disorders
Conditions related to sexual health
Extension codes

ICD-11
Foundation component
URI
Multiple parents
Stem codes and extension codes
Code combinations
Conventions
Alphabetic index

International Classification of Functioning, Disability and Health (ICF)
Used to measure health and disability
Print and online
Assignment by a health professional

ICF
Components
Body functions
Activities and participation
Environmental factors
Body structures

International Classification of Diseases for Oncology, Third Edition (ICD-O-3)
Derived classification
Used by tumor or cancer registries
Reports topography and morphology of neoplasm
Print and online

ICD-O-3
Used to report cancers to state and national registries
Dual classification
Greater detail of the histology than ICD-10

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
Classification for mental disorder
Print, online, and in software applications
Determination of a mental disorder by a clinician
ICD-10-CM codes incorporated into DSM-5
Used for
Clinical assessments
Developing treatment plans
Communicating between healthcare providers

Code System
An accumulation of terms and codes for exchanging or storing information
Broad term
Characteristics of a terminology or a classification
Primary or secondary data use

Logical Observation Identifiers, Names, and Codes (LOINC)
System for identifying health measurements observations, and documents
No book of codes or no assignment by a coding professional
Implemented in software applications

LOINC
Standardizes names and codes for the identification of laboratory and clinical variables
Fully specified name made up of five or six parts
Facilitates sharing of data
Standard for certified EHR systems

Healthcare Common Procedure Coding System (HCPCS) Level II
Two code systems
Level I: CPT
Level II: professional services, procedures, products, and supplies
Level II published by CMS
Updated quarterly
Print, online, and in software applications
Standard for certified EHR systems

HCPCS Level II
Assignment by a professional coder
Used for reimbursement of ambulatory care
Modifiers

RxNorm
Standardized nomenclature for clinical drugs
No book of codes or no assignment by a coding professional
Implemented in software applications
Interim updates: weekly and full update monthly
Standard for certified EHR systems

RxNorm
Used to communicate drug related information
Standard for certified EHR systems
Concept unique identifier
Semantic clinical drug term type
Ingredient
Strength
Dose form

Health Data and Information Sets
Data set: list of recommended data elements with uniform definitions
Data collected used for
National and state statistics
Clinical decision support
Clinical quality measures

Outcomes and Assessment Information Set (OASIS)
Collected on Medicare beneficiaries receiving skilled services from a Medicare-certified home health agency
RN and therapists collect the data
Home health agency process and improvement outcome measures based on OASIS data

Healthcare Effectiveness Data and Information Set (HEDIS)
Sponsored by NCQA
Designed to collect administrative, claims, and health record review data
Form the basis for performance improvement
Use by healthcare purchasers and consumers to compare performance

Uniform Hospital Discharge Data Set (UHDDS)
Data collected by acute care, short-term stay hospitals
Core data elements incorporated into IPPS
Example: principal diagnosis

Common Clinical Data Set
Established by the ONC
Originated from federal reporting requirements tied to certification criteria
Some but not all have a standard attached
Example: SNOMED CT attached to the data element smoking status

Database of Clinical Terminologies, Classifications, and Code Systems
Unified Medical Language System (UMLS)
Centralized location of health and biomedical terminologies and standards
UMLS Knowledge Resources
Metathesaurus
Semantic Network
SPECIALIST Lexicon and Lexical Tools

Metathesaurus
Contains codes and terms from over 200 terminology, classification, and code systems
Examples: SNOMED CT, ICD-10-CM, and LOINC

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This is what I’m gonna be going each week for this project. So we are going (

2. Teach

) a,b and c next week.

Project: HIT Educator Simulation

1. Review

a. Review the resources available for educators in the health information field. These resources include the following. b. AHIMA Academic Center: https://www.ahima.org/education-events/academic-center/

c. Commission on Accreditation for Health Informatics and Information Management i. www.cahiim.org ii. https://www.cahiim.org/accreditation/forms-fees-and-documents/cahiim-process-forms/him-process-forms

iii. In the second link, review the curriculum requirements form.

d. Bloom’s Taxonomy i. https://cft.vanderbilt.edu/guides-sub-pages/blooms-taxonomy/

2. Teach

a. Select three chapters from your Sayles textbook

b. Create a chapter outline

c. Create a recorded lecture for each chapter

i. You can create this recording through PowerPoint or the Studio function in IvyLearn

3. Create

a. Select five competencies from the curriculum requirements form that you reviewed from the CAHIIM website.

b. Create an activity or assignment that will meet the appropriate level of Bloom’s Taxonomy.

i. Create an assignment or activity document that contains all of the necessary student instructions.

ii. Create an answer key or instructional guide that will assist in the grading of this assignment.

4. Present

a. Create a brief presentation about what you have learned about the education side of health information

b. Share the activities that you have completed in your externship.

i. You do not need to show the recorded lectures that you create.

ii. Describe the curriculum competencies that you selected, as well as the Bloom’s Taxonomy levels required to meet the selected compet

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