HCA521 Unit 5 Primary and Secondary Health Records Paper

M05_GART2674_01_SE_C05.QXD 5 8/10/09 9:52 AM Page 98 Healthcare Records LEARNING OUTCOMES After

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completing this chapter, you should be able to: 䊏 Discuss the functions that healthcare records serve H primary and secondary health records 䊏 Explain the difference between 䊏 Identify different forms used I to record patient information 䊏 Discuss standard data elements and standard data sets G 䊏 Explain how health records assist in the continuity of care G 䊏 Define a RHIO 䊏 Describe the various formsSof telemedicine 䊏 Explain an E-visit , ACRONYMS USED IN CHAPTER 5 S H Acronyms are used extensively in both medicine and computers. The following A acronyms are used in this chapter. ALOS Average Length of Stay N NCVHS CDC Centers for Disease Control I and Prevention National Committee on Vital Health Statistics NHIN National Health Information Network OASIS Outcome and Assessment Information Set CMS CPR CT Centers for MedicareC and Medicaid Services Q Cardiopulmonary Resuscitation U Computed Tomography (also A CAT, Computerized Axial PACS OR PAC SYSTEM Picture Archiving and Communication System Tomography) PET Positron Emission Tomography DEEDS Data Elements for Emergency Department Systems 1 PHI Protected Health Information PHR Personal Health Record DNR Do Not Resuscitate RAI Resident Assessment Instrument RHIO Regional Health Information Organization SNF Skilled Nursing Facility SOAP Subjective, Objective, Assessment, Plan UACDS Uniform Ambulatory Care Data Set ECG EEG EHR EKG HEDIS 1 Electrocardiogram (also EKG) 0 Electroencephalogram 5 Electronic Health Record T ECG) Electrocardiogram (also Health Plan EmployerS Data and Information System HPI History of Present Illness IDN Integrated Delivery Network LOS Length of Stay MDS Minimum Data Set MPI Master Patient Index MRI Magnetic Resonance Imaging NCDB National Cancer Data Base UAMCMDS Uniform Ambulatory Medical Care Minimum Data Set UCDS Uniform Clinical Data Set UHDDS Uniform Hospital Discharge Data Set 98 Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 99 HEALTHCARE RECORDS 99 Understanding Healthcare Records Healthcare records have many purposes, the most important of which is to help healthcare providers with patient care. The patient health record is the repository of data and information about the patient, the condition of the patient’s health, the care and treatments the patient received, and the outcome of that care. This chapter will familiarize you with some of the contents of health records and how they are used. The term patient health record has replaced the term patient medical record because it encompasses a holistic view of patient care. Though the terms are used almost interchangeably, an acute care patient record is usually concerned with one stay or episode, whereas an outpatient medical record is usually limited to one group or clinic. Later in this chapter we will discuss efforts to overcome these limitations by regional providers sharing records electronically and the growing interest by patients in maintaining lifelong personal health records. In Chapter 4 the term data was used to differentiate the H information the computer processes from the software application. In this and future chapters theIword data does not just mean computer information, but rather the information in a health record. Additionally, the term health data G is sometimes used herein for what is technically health information. In a more precise definition, data and information are not the same thing. Data are records G of facts. Information is data in a useful form that conveys meaning. For example, the numeric values 68, 70, 72 are data. S 䊏 䊏 If the data represent height in inches, they may be used to plot an adolescent’s growth rate. , If the data represent a patient’s pulse, they are used to provide information about the patient’s heart rate measured at different intervals. Health information, therefore, is not just the patient dataS but the presentation of this data in a useful form and the association of other relevant details with H it. Figure 5-1 shows a standard form used in pediatric practices. When patient height is recorded on this form, the doctor can easily see A a boy’s height to the general popthe rate of growth over time. Curved lines on the form compare ulation at the same age. In this chapter we will examine some N typical health information forms and further explore the concepts of data elements and data sets introduced in the previous chapter. I C Functions of Healthcare Records Q U A patient’s health record provides accurate information not only about the patient’s treatment, but also about the patient’s health history and previous treatments. A As such, it serves as the primary communication document among various providers who might care for the patient at different times in different departments. The patient record also provides the basis for all billing 1 and reimbursement. Coding professionals review the record of the patient visit and determine 1 what codes to put on the insurance claim. CMS and other health insurance auditors follow the dictum that “if it isn’t documented, it wasn’t done,” meaning that medical claims will not be paid0if the patient record does not have enough detail about the encounter or treatment to support the5claim. The health record is a legal document. Should a question arise as to the cause of a disease or injury, or to determine if a medical error was made, relevant T portions of the patient’s record may become evidence in a court of law. S Healthcare records provide the basis for improvements in health. Individually, a patient’s record is evaluated and used to develop care plans for the patient. Collectively, health records can be used by the healthcare facility to improve the quality and processes of healthcare delivery. Public health departments, Homeland Security, and law enforcement officials use information from health records to track births, deaths, communicable diseases, effects of exposure to hazardous materials, bioterrorism threats, gunshot wounds, child abuse, and other crimes. Researchers use patient records from clinical trials to monitor the effectiveness and safety of new drugs. De-identified health records are analyzed by researchers to find health trends in our society and measure which treatments seem to have the best outcomes. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 100 8/10/09 9:52 AM Page 100 CHAPTER 5 2 to 20 years: Boys Stature-for-age and Weight-for-age percentiles Mother’s Stature Date Father’s Stature Age Weight Stature BMI* NAME RECORD # 12 13 14 15 16 17 18 19 20 cm AGE (YEARS) 95 90 75 50 25 in 62 S T A T U R E 60 58 56 54 52 50 48 46 44 42 40 38 cm 3 4 5 6 7 8 9 H I G G S , 160 155 150 145 140 135 130 125 S H A N I C Q U A 120 115 110 105 100 95 36 90 34 85 32 80 30 80 W E I G H T 70 60 50 40 30 lb 10 5 10 11 35 30 25 20 15 10 kg 2 3 4 5 6 7 8 9 1 1 0 5 T AGE (YEARS) 10 11 S12 13 190 185 180 175 170 165 160 155 150 in 76 74 S T A T U R E 72 70 68 66 64 62 60 105 230 100 220 95 90 95 210 90 200 85 75 80 75 50 25 10 5 190 180 170 160 70 150 W 65 140 E I 60 130 G 55 120 50 110 H T 45 100 40 90 35 30 25 20 15 10 kg 14 15 16 17 18 19 20 80 70 60 50 40 30 lb Published May 30, 2000 (modified 11/21/00). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts FIGURE 5-1 Pediatric Growth Chart of Boys’ Stature for Age and Weight for Age. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 101 HEALTHCARE RECORDS 101 Primary and Secondary Records Health information professionals classify health records as primary or secondary records: 䊏 䊏 Primary records are those that are gathered directly from the patient and his or her providers, as well as records obtained from devices and diagnostic tests performed on the patient. Primary records are used for patient care and as legal documents. Secondary records are those that are created later, by analyzing, summarizing, or abstracting from the primary records. Secondary records are used in billing, research, and quality improvement. Types of Primary Health Records Primary records may be electronic medical records or paper forms, but what they have in comH mon is that they document the patient’s history and state of health, the clinician’s observations and actions, and all tests, treatments, and outcomes. As such,Ithe patient’s health record at a given facility is actually a collection of documents or computer records, G descriptions of which are provided later in this chapter. G As you have learned in previous chapters, there are differences between inpatient and outpatient facilities. The type and quantity of information they keep also varies by the type of facility. S For example, primary health records are generated and maintained by patients, doctors, nurses, , chiropractors, and others. home health providers, hospitals, rehabilitation facilities, dentists, The following examples illustrate some of the differences between health records at different providers’ locations: S 䊏 䊏 䊏 䊏 Acute care hospital charts contain admission and discharge reports, nursing notes, physician examination notes, all orders, test results, operativeHreports, pathology and radiology reports, and administrative and demographic forms. However, A in nearly all cases these are concerned with the current stay. N Ambulatory care facilities (physician offices) tend to keep a single chart per patient, combinI ing documents from all previous visits, medical history, consults, lab results, and reports from other providers. The principal document is the physician’sCnote, which details the observation and findings, but often includes the physician’s orders and plan of treatment. In addition to demographic and social history information, many officesQkeep records of communications with the patient and their insurance plans in the chart as well. U Home care agency records are uniquely centered on a physician’s orders for treatment at A home. CMS has standardized the details that are required about a patient’s home care. The nurses or therapists visiting the patient at home keep notes from each visit concerning the services performed and the patient’s progress. These are1updated in records maintained by the home care agency. 1 Dental records generally contain very abbreviated notes about the treatments and proce0 ever had with the practice includdures performed, but usually cover all visits the patient has ing dental hygienists and other dentists. Also, because dental 5 x-rays are small, most offices store them in the patient’s chart. This is different from medical facilities where x-rays and other diagnostic images are typically stored in a separateTlocation or computer system. S Types of Secondary Health Records Secondary health records are those that are created by abstracting relevant details from the primary records. These secondary records are used for reimbursement (insurance claims), quality improvement at the facility, reporting to accreditation and government agencies, and research. The following are some examples of secondary health records: 䊏 Health insurance claims are created by selecting information from the patient record, such as procedures and diagnoses, assigning codes to them, and assembling them with information from the patient’s demographic and insurance information. These are then submitted to the insurance plan for payment. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 102 8/10/09 9:52 AM Page 102 CHAPTER 5 䊏 䊏 The master patient index (MPI) is typically a computerized system intended to prevent duplicate registrations for the same patient. By taking key identifying facts from patient demographic information such as full name, date of birth, gender, and sometimes Social Security number, a list is created of all the patients registered anywhere in the healthcare facility. By checking the MPI first, registration clerks can see if the patient is already registered and thereby avoid creating duplicate records in the system. Aggregate data is collected by gathering selected items of information from many patients’ charts and then analyzing it. For example, in Chapter 1 we discussed ALOS or average length of stay. By extracting the LOS of all of the patients in the hospital last month, the hospital can calculate the average. Similarly, aggregate data can be analyzed to determine the case mix or for quality improvement purposes. Case mix will be described further in Chapter 9. Transition from Paper to Electronic H Records Many social forces and practical reasons I are causing healthcare providers to change from paper health records to electronic health records (EHRs). Social reasons include an increasingly mobile G doctors more frequently. Additionally, many patients society where patients move and change today see multiple specialists for theirG care. This means their medical record no longer resides with a single general practitioner who provides their total care. Thus, the ability to share examination records and test results is increasinglySimportant to the patient’s continuity of care (discussed later in this chapter). , Practical reasons for the move to EHRs include the fact that paper records cannot be easily accessed or shared, the charts must be copied and faxed or transported from one office to another, and handwritten portions of the record S are often abbreviated, cryptic, or illegible. Finally, searching the contents of paper charts requires manually opening every chart and reading it. H Chapter 7 will cover ways EHR systems can be used to help improve patient health, the quality of care, and patient safety by Aproviding access to complete, up-to-date records of past and present conditions. Though many facilities are moving toward electronic health records, the N transition will take several years. I C Contents of Health Records Q Although the types of documents or data contained in medical records differ between inpatient U and outpatient facilities, many of them serve a similar purpose. However, clinical records are not the only items stored in a patient’s chart. A For example, many ambulatory offices store nearly any document concerning a patient in the patient’s chart. Figure 5-2 compares a list of some typical records in an inpatient and outpatient chart. Additional information and samples of many of the 1 forms are provided later in this chapter. 1 Data Administrative and Demographic Whether health records are paper or0electronic, certain administrative documents tend to originate as paper forms. Generally this5is the registration information provided by the patient or relative and certain legal documents that the patient must sign. In an all-digital facility these T paper documents are subsequently scanned as images and stored in the electronic record. When a patient is first registered, demographic data such as name, address, phone numbers, S next of kin, and emergency contact information is recorded. Registration will also record information used for billing such as account guarantor and insurance plans. Though some facilities allow the patient to enter this information directly using a web page, most facilities employ a registrar to enter the data into a computer. In a paper-based facility the patient demographics form is called the face sheet. In facilities that are still transitioning from paper to electronic records, the information may be entered into the computer then printed out to create a face sheet for the paper chart. Demographic and billing information is verified and updated if necessary for each return visit. Patients’ insurance cards may also be photocopied or scanned into the computer during registration. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 103 HEALTHCARE RECORDS Comparison of Contents of Patient’s Chart Acute Care Hospital Registration Record Consent Forms, Authorizations, Property list, Advance Directives Medical History (Admitting Doctor) Physical Examination (Admitting Doctor) Doctor’s Office 103 FIGURE 5-2 Contents typical of acute care versus ambulatory patient charts. H RegistrationIForm G Authorizations, Advance Consent Forms, Directives G Medical History (From Patient) S Doctor’s Notes , from each visit. (Complaint, Symptoms, History, Review of Systems, Vital Signs, Physical Exam, Assessment, Plan of Care) Physician Orders S orders and Test Results Diagnostic Test Clinical Observations: Doctors’ notes, Nurses’ notes, Therapy notes Flow sheetsH (specialty specific—pediatric, obstetric, etc.) Surgery Report/Anesthesia Record Medical Records from other providers Consultation Reports Test Results Discharge Summary Patient Discharge Instructions A N ConsultationI Reports Problem List C Medication Q List Immunization U Record Correspondence A Authorization forms to Disclose PHI Copies of Insurance Cards 1 1 Consent and Directives 0 A number of legal documents signed by the patient are included in the medical record. In some 5 cases these are simple permission statements included on the patient information form; in other T filed in the chart or scanned into facilities the patient signs many individual forms, which are then the computer. Some typical examples include the following. S The patient acknowledges receipt of the Notice of Privacy Practices discussed in Chapter 3. This consent or acknowledgment may be included on the registration form or combined with another consent form. HIPAA CONSENT TO USE AND DISCLOSE PHI CONSENT TO TREATMENT A general consent to be treated by the healthcare practice or facility is usually included in the registration form. Additional informed consent forms are required for each operation or special procedure (discussed below). CMS requires that patients be given a statement of their rights under Medicare. Patients will sign an acknowledgment that they have received the statement and their rights have been explained. MEDICARE PATIENT RIGHTS STATEMENT Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 104 8/10/09 9:52 AM Page 104 CHAPTER 5 ASSIGNMENT OF BENEFITS In order for a healthcare facility to be reimbursed by Medicare and other insurance plans, the policy holder must sign a form permitting the plan to pay the provider directly. This is called the assignment of benefits, and may be part of the insurance portion of the registration form or may be a blank insurance claim form signed by the policy holder. Note that a CMS-1500 paper insurance form has two signature blocks; one authorizes the patient’s medical information to be sent to the plan and the other authorizes the assignment of benefits to the provider. (Refer to Chapter 10, Figure 10-4, to view an example of this form.) Written consent forms are signed by the patient or patient’s legal representative before any operation or special procedure. The informed consent describes what is going to be done, the expected outcome, any risks associated with it, and possible alternatives to the procedure. This is done to ensure the patient has a complete understanding before going forward. Figure 5-3 shows a two-sided informed consent form. INFORMED CONSENT H A patient may elect not to have a medically necessary procedure I done. In such a case, a form documenting that the consequences of the decision are fully understood by the patient is signed and G added to the chart. REFUSAL OF TREATMENT An advance Gdirective is sometimes called a living will and permits patients to provide instructions regarding resuscitation and life-prolonging procedures in the S event the patient should become terminally ill or injured and unable to communicate his or her , wishes. The advance directive or separate document may also grant another person the power to make medical decisions on the patient’s behalf should the patient become incapacitated. The advance directive may include instructions not to resuscitate the patient in the case of death. When this is the case, inpatientSfacilities create a special order in the chart and clearly mark it DNR (do not resuscitate). If a DNR Horder is not present, consent to perform cardiopulmonary resuscitation (CPR) is presumed. ADVANCE DIRECTIVES A If a patient has agreed to donate organs or other tissues upon death, this is also N specifying an organ donor status, the patient’s family noted in the record. If a patient dies without must be given the opportunity to authorize organ donation. I ORGAN DONOR PERSONAL PROPERTY LIST Inpatient Cfacilities may create a list of personal property brought to the facility by the patient such as jewelry, eyeglasses, hearing aids, and dentures. The form, signed by the patient, may release theQfacility from responsibility for loss or damage to the items. A similar disclaimer may absolve the Ufacility of responsibility for a patient’s vehicle parked on the premises while staying there. A As discussed in Chapter 3, HIPAA requires any disclosure of PHI for purposes other than treatment, payment, or operations of the facility to be tracked and 1 authorizations permitting release of partial or complete recorded. In addition, copies of signed medical records are kept by the HIM 1 department, sometimes with the health record itself. DISCLOSURE RECORDS 0 5 As you would expect, most of the information in the patient’s medical record will be of a clinical nature. In both paper and electronicTsystems, diagnostic images are stored separately from the chart documents or data; however, some EHR systems may provide seamless access to images, S within one system. In paper systems x-rays films are giving the appearance that they are located Clinical Documents stored separately, usually in another part of the hospital. The following are clinical documents typically found in the health record. The primary source of a patient’s medical history is the patient or a relative. A medical history at an acute care facility will be obtained through an interview of the patient by the admitting doctor or a nurse. At an ambulatory facility the history typically originates as a paper form that is filled out by the patient in the waiting room, though some modern medical practices allow patients to enter this data themselves on a computer using medical history software. A sample paper history form is shown in Figure 5-4. MEDICAL HISTORY Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 105 HEALTHCARE RECORDS 105 H I G G S , S H A N I C Q U A 1 1 0 5 T S FIGURE 5-3a Informed Consent (front side). Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 106 H I G G S , S H A N I C Q U A 1 1 0 5 T S FIGURE 5-3b Informed Consent (back side). Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 107 HEALTHCARE RECORDS 107 Date: ______________ Patient Name: ________________________________________________________ Date of Birth: Race: ______________ ❒ Male ❒ Female Family Practice Medical Center Anytown, USA What is the reason you are here today? ___________________________________________________________________________________________________________________________________________________ Please check any of the following conditions which you have had General ❒ Serious Infections (e.g. pneumonia) ❒ ❒ ❒ ❒ HEENT ❒ Glaucoma ❒ Allergies “hay fever” ❒ Frequent Ear Infections ❒ Frequent Sinus Infections Diabetes Mellitus Rheumatic fever HIV Infection Cancer Respiratory Cardiovascular ❒ ❒ ❒ ❒ ❒ ❒ ❒ ❒ ❒ ❒ ❒ High Blood Pressure Congestive Heart failure Heart Murmur Heart Valve Disease Angina Heart Attack High Cholesterol Abnormal Heart Rhythm Blood Clot in Veins Blocked Arteries in Neck Blocked Arteries in Legs ❒ ❒ ❒ ❒ Asthma Emphysema Blood Colt in Lungs Sleep Apnea Musculoskeletal / Extremities ❒ ❒ ❒ ❒ ❒ ❒ Osteoporosis Rheumatoid Arthritis Degenerative Joint Disease Fibrmyalgia Neck Pain (herniated disk) Back Pain (herniated disc) GI/GU ❒ Stomach Ulcers ❒ Ulcerative Colitis ❒ Crohns Disease ❒ Bleeding from Intestines ❒ Diverticulitis ❒ Colon Polyps ❒ Irritable Bowel Disease ❒ Hepatitis ❒ Cirrhosis of the liver ❒ Liver Failure ❒ Pancreatitis ❒ Gallstones ❒ Kidney Stones ❒ Kidney Failure ❒ Prostate Disease ❒ Endometriosis ❒ Sex Transmitted Infection H I G G S , S H A Please check any of the following major illnesses in your family members: N❒ Kidney Disease ❒ Tuberculosis ❒ Diabetes Mellitus ❒ Emphysema ❒ Thyroid Disease I❒❒ Epilepsy ❒ Heart Disease ❒ Anemia Neurological Disorder ❒ High Blood Pressure ❒ Hemophilia C❒ Liver Disease ❒ Osteoporosis ❒ Other _____________________ ❒ Other _____________________ Q U If you have had surgery please indicate the year: Year Surgery Year Surgery Year Surgery A Neurosurgery _____ Angioplasty _____ Colonoscopy _____ _____ _____ _____ _____ _____ _____ Appendectomy Back or Neck Surgery Bladder Surgery Carotid Artery Surgery Carpal Tunnel Surgery Chest/lung Surgery _____ _____ _____ _____ _____ _____ Coronary Bypass Ear Surgery Gallbladder Hip Surgery Inguinal Hernia Knee Surgery _____ _____ _____ _____ _____ _____ 1 1 0 Please indicate when you had the following preventative services: Date Immunizations Date T ests Date 5 _____ Flu Vaccine _____ Chest X-ray _____ _____ Hepatitis Vaccine _____ EKG _____ T _____ Pneumonia Vaccine _____ Echocardiogram _____ _____ Tetanus Booster _____ Stress Test _____ S _____ Other _____ Cardiac _____ Angiogram S inus Surgery S tomach Surgery Thyroid Surgery T onsillectomy Trauma Related Surgery Vascular Surgery T ests / Exams Colon Cancer Stool Test Flexible Sigmoidoscopy, R ectal Exam Barium Enema Prostate Cancer Blood Test Lymphatic / Hematologic ❒ Thyroid Goiter ❒ Over Active Thyroid ❒ Under Active Thyroid ❒ Transfusions ❒ Anemia Skin / Breast ❒ ❒ ❒ ❒ Acne Eczema Psoriasis Fibrocystic Breast Disease Neurological / Psychiatric ❒ ❒ ❒ ❒ ❒ ❒ ❒ Chronic Vertigo (Meniere’s) Peripheral Nerve Disease Migraine Headaches Stroke Multiple Sclerosis Depression Anxiety ❒ ❒ ❒ ❒ ❒ Breast Cancer Ovarian Cancer Colon Cancer Prostate Cancer Other _____________________ Year _____ _____ _____ _____ _____ _____ _____ Date _____ _____ _____ _____ _____ Surgery Tubal ligation C-Section Hysterectomy Ovary Removed Breast Surgery T hyroid Surgery Other T ests / Exams Breast Exam Mammogram P ap Smear B one Density Test Date of last Physical Exam Personal Habits Tobacco ❒ Never ❒ Previous user ❒ Current user # packs per day __________ FIGURE 5-4 Alcohol ❒ Never ❒ Previous user ❒ Current user # drinks per day __________ Caffeine ❒ Never ❒ Previous user ❒ Current user # cups per day __________ Illicit Drugs ❒ Never ❒ Previous user ❒ Current user Outpatient History Form (paper version). Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 108 8/10/09 9:52 AM Page 108 CHAPTER 5 The patient’s history for an ambulatory visit includes: 䊏 䊏 䊏 䊏 䊏 䊏 Chief complaint (principal reason for the visit) History of present illness Past medical history, including previous illnesses, operations, serious injuries, childhood diseases, drug and environmental allergies, and immunization records Social history concerning living conditions and habits such as smoking, drinking or drug usage Family history to determine if close relatives have certain chronic diseases or allergies that may be hereditary Review of systems, which involves questions about one or more of 11 body systems. The patient’s medical history will be reviewed and updated for each outpatient visit. H PHYSICAL EXAM Detailed records are I made of each physical exam; these are generally encompassed in the physician’s note along with the medical history discussed above. The physician’s note is sometimes called the SOAPG note, which is an acronym for a recommended format for physician notes. SOAP stands for: G Subjective: S 䊏 The patient’s description of symptoms and the chief complaint , Objective: 䊏 The findings of the physical exam and diagnostic tests S H A Plan: N 䊏 Physician’s orders and plan of care for the treatment of the condition. I Generally a history and physical are conducted at every outpatient visit. Cnotes are used to document the patient’s condition and After the initial exam, progress response to treatment and any modifications to the plan of care or additional orders. Physician Q progress notes may follow the SOAP format as well. Inpatient rules require a historyU and physical within 30 days prior to admission or no more than 24 hours after admission. A Assessment: 䊏 The physician’s diagnosis Nursing progress notes for inpatients will usually be grouped elsewhere in a nursing notes section of the chart (discussed later in this chapter.) 1 Each order for a medication, lab work, or other 1 diagnostic test will be recorded in the patient’s chart. Orders are also recorded for ancillary 0 and occupational therapy. services such as respiratory, physical, Orders must be dated and signed 5 (or electronically signed) by an authorized person. Generally this is a physician, physician assistant, or certified nurse practitioner. A sample order T form is shown in Figure 5-5. In hospitals, physicians often give S or change orders verbally. The order is then entered and DIAGNOSTIC AND THERAPEUTIC ORDERS signed by a person authorized to receive verbal orders (usually a licensed nurse.) Inpatient orders may also concern dietary restrictions, restraint, seclusion, and so on. Inpatient facilities also require a discharge order when the patient leaves. Outside the hospital, orders are also required for medical equipment, devices, and home health services. For each test or diagnostic study ordered, the chart should also contain a report of the results. X-rays and other radiology studies will be interpreted by a radiologist who will dictate a report; laboratory work will generate a lab results report or pathology report. DIAGNOSTIC AND THERAPEUTIC REPORTS Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 109 HEALTHCARE RECORDS 109 H I G G S , S H A N I C Q U A 1 1 0 5 T S FIGURE 5-5 Form for Orders Following Surgery. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 110 8/10/09 9:52 AM Page 110 CHAPTER 5 Physical, occupational, respiratory, speech, and other types of therapists record the patient’s progress and the outcome of the ordered therapy. These too are part of the patient record. A nutritional or dietary plan will be part of inpatient records. The actual images or data captured from ordered tests is retained as part of the patient record. These are generally stored separately from the chart, though in an electronic medical record they may appear integrated. If an x-ray is taken on film, the films are stored in large envelopes called jackets, usually in a separate file room. Many hospital radiology departments have eliminated film and either capture the x-ray directly into the computer, or scan the film during processing and store the image electronically. Radiology departments generally store images on a Picture Archiving and Communication System (PACS). These include x-rays, CT scans, PET scans, and MRIs. Other diagnostic tests may produce images that are stored in the medical record, but not on the PAC system. Examples of these are EKGs, EEGs, and ultrasound H images. DIAGNOSTIC IMAGES I Surgical procedures require records of the anesthesia, the actual proceedings in the operating room (intraoperative records), the period in the recovery room, and G a postoperative progress note. An informed consent for the procedure signed by the patient or legal representative is required and isG usually grouped with the operative records. If the operation involves organ transplantation, additional S transplant records are required. Refer to Figure 5-3 to view an informed consent form. OPERATIVE RECORDS , Information gathered by nurses on an outpatient visit may include the chief complaint, past medical history, family history, and social history, and the vital signs. In an Skept as separate nursing notes, but rather made a part of the outpatient setting these are usually not physician’s SOAP note. H In an inpatient facility, nurses provide most of the care and record most of the information about the patient. Nursing notes areA therefore grouped separately by most systems. In addition to recording the patient’s medical, social, N and family history upon admission, nurses document the administration of medications, therapies, oxygen, and other treatments ordered by the I physician. Nursing notes are the key to continuity of care for the inpatient. Nurses document not only C the treatment interventions but the patient’s response to treatment, and record observations on Q changes in the patient’s status or deviations from the plan of care. Any abnormal conditions or new complaints that arise are recorded by the nurses. In addition to frequent monitoring of vital U signs, nurses also record the level of pain the patient is experiencing and the input and output of A fluids by the patient. A nursing assessment of the patient is performed at each work shift and all nursing notes are signed by the nurse. Because nurses provide most of the direct treatment to the patient, nursing 1 notes usually make up the largest portion of an inpatient medical record. Figure 5-6 shows a method for1recording nursing notes using a flow sheet. A flow sheet records data in columns and rows, making it easy to compare changes in values recorded over 0 multiple intervals of time. NURSING NOTES 5 Specialists may be asked to see a patient or review a case. In both T inpatient and outpatient settings, consulting physicians will provide a document of their findings for the patient’s medical record. A S copy of the attending physician’s request for the consult, called a referral, may be kept in the medical record as well. Some insurance programs require a formal preauthorization for outpatient referrals; in such cases, a copy of that preauthorization is also placed in the patient’s chart. REFERRAL CONSULTS CASE MANAGEMENT Case managers and social workers document care planning, coordination of care, and discharge plans in an inpatient facility medical record. DISCHARGE SUMMARY Inpatient stays of longer than 48 hours are concluded with a discharge summary report created by a physician. Shorter stays may have a final discharge progress note or short-stay report used in place of the discharge summary. A final physical exam is conducted. It Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:52 AM Page 111 HEALTHCARE RECORDS 111 H I G G S , S H A N I C Q U A 1 1 0 5 T S FIGURE 5-6 Nursing Flow Sheet chart used in a neonatal unit Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.qxd 112 10/5/09 7:43 PM Page 112 CHAPTER 5 H I G G S , S H A N I C Q U A 1 1 0 5 T S FIGURE 5-7 A Discharge Summary Form Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:53 AM Page 113 HEALTHCARE RECORDS 113 may be recorded with the discharge summary or as a separate physician note. An example of a discharge summary form is shown in Figure 5-7. Elements in the discharge summary include: 䊏 䊏 䊏 䊏 䊏 䊏 Principal diagnosis and other diagnoses Brief history justifying the need for hospitalization Summary of laboratory, radiology, and other diagnostic results Significant treatments and procedures as well as the patient’s response to them Patient’s condition at the time of discharge Plan of care: follow-up visits, dietary restrictions, referrals to other providers, prescriptions and orders for medications and durable medical equipment such as a wheelchair or crutches, and orders for home oxygen or therapy. H typically create prenatal records Physicians who deliver maternity care within the chart to document each pregnancy separately. These I often take the form of a flow sheet or grid on which observations at each visit are documented in columns, allowing for easy G the term of the pregnancy. comparison of the patient’s condition on multiple visits during OBSTETRICAL RECORDS G above, children’s health records In addition to the documents discussed also contain growth charts graphing a child’s rate of growth S as compared to a national reference group (shown in Figure 5-1). Children also receive a series of immunization vaccines intended to prevent disease. Immunization records are kept in the child’s, chart. Copies of the immunization record are used for admission to school, after-school programs, and sometimes summer camps. Physicians may also be required to send immunization records to their state health departments. PEDIATRIC RECORDS S Outpatient charts also include a problem list, which provides an up-to-date list H of both acute and chronic conditions that affect the patient’s care. Problem lists usually have an onset date, a description of the chronic or acute condition, Aand a status (for example, if the problem is better, worsening, well controlled, or resolved.) Once a problem is resolved, it is N considered inactive or removed from the list. I Though chronic diseases that are poorly controlled or malignancies take precedence in clinical decision making over mild conditions that are not life threatening, the idea of a problem list C is to make sure that every provider who touches the patient knows what conditions are present. Q A problem list is required by the Joint Commission for ambulatory charts. PROBLEM LIST Uis also used in an outpatient chart. Similar to a problem list, a medication list Various prescription drugs can nullify the benefits of otherA drugs or cause serious interactions with other drugs. It is important to know all of the medications a patient is currently taking before prescribing medication or changing a patient’s existing prescription. Healthcare providers need a medication list for two reasons: 1 MEDICATION LIST 䊏 䊏 Outpatient charts tend to have orders buried in the plan section 1 of progress notes. A medication list brings them all together in one place. 0 Many patients receive prescriptions from multiple specialists. A medication list is necessary to record drugs the patient is taking that were prescribed5 elsewhere. Public Health Records T S Several types of inpatient records are related to birth and death, as discussed next. BIRTH Newborns are separate patients from their mothers and, therefore, have their own medical record started at birth. This includes examination notes and several measures of the child’s size and condition. A discharge summary is not usually required for infants born without complications. A baby’s birth also requires a document recording the birth, which is signed and sent to the state health department. When a patient dies in the hospital, a note of the time and date of death is entered in the chart with a note by the attending physician. In all cases of death, a discharge summary is DEATH Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 114 8/10/09 9:53 AM Page 114 CHAPTER 5 required for the record. If an autopsy is performed, a report of the autopsy results will be recorded as well. A record of the death is sent to the state health department. DISEASE To prevent epidemics, cases involving certain serious communicable diseases are reported to the public health department and/or the Centers for Disease Control and Prevention (CDC). Plan of Care Though a plan of care is present in the outpatient’s progress notes and the inpatient’s discharge summary, both long-term care facilities and home care agencies use a plan of care document that is central to their chart. In a skilled nursing facility (SNF) the form is called a Resident Assessment Instrument (RAI). These are updated regularly, following reassessment of the patient at defined intervals or if a significant change in the patient’s condition occurs. A sample RAI form is shown in Chapter 9 H Figure 9-14. I In home care, the principal document is the home health certification/plan of care. The patient’s doctor reviews and updatesG the certification every 60 days. Home health agencies use a standard called the Outcome and Assessment Information Set (OASIS) to document data that is G every 60 days. sent electronically to the state and CMS S , Documentation Standards S Whether patient health records are paper or electronic, it is important for them to be uniform, H and available. Several tools that HIM professionals use to accurate, legible, complete, up to date, ensure uniform quality patient records A are standardized data elements, data sets, and HIM policies and procedures. N I Data Elements Chapter 4 introduced the term data C elements. Remember that data elements are not necessarily a data field, but rather a component of the record that may require several fields. For example, a Q standard data element is patient name. However, it is not uncommon for a paper form to have separate boxes labeled “last name,” U “first name,” and “middle initial.” A computer database will certainly store the name as three or more fields. Yet the three fields together make up one eleA ment: the patient name. The concept of standard data elements applies equally to paper or electronic records. Including standard data elements in a1form or database design makes it likely that the record will have data similar to that of other healthcare systems. This not only improves interoperability, but 1 provides common elements for system-wide reports. The National Committee on Vital 0 Health Statistics (NCVHS) has developed a list of core data elements from a comparison of several of the health data sets standards discussed below. The 5 in Figure 5-8. NCVHS recommendations are provided Data Sets T S A data set is a list of data elements collected for a particular purpose. For example, an admission record would need all the data elements of the patient demographics, insurance information, next of kin, and so on. In a paper system, this would be done by making sure the paper form contained all of the appropriate boxes and that they were filled in correctly. In an electronic system, many elements of the data are entered only once, and then assembled into the data set as needed. For example, the patient demographics and insurance and next of kin information would be retrieved from the patient registration system without reentering the data. Usually standard healthcare data sets represent the minimum list of data elements that must be collected. Often the number of data elements collected and retained by a healthcare organization vastly exceeds the requirements of the minimum data sets. Some data sets are Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:53 AM Page 115 HEALTHCARE RECORDS Core Data Elements Recommended by NCVHS 1. Personal/unique identifier 21. Attending physician identification (inpatient) 2. Data of birth 22. Operating clinician identification 3. Gender 23. Health-care practitioner specialty 4. Race and ethnicity 24. Principle diagnosis (inpatient) 5. Residence 25. Primary diagnosis (inpatient) 6. Marital status 26. Other diagnosis (inpatient) 7. Living/residential arrangement 27. Qualifier for other diagnosis (inpatient) 8. Self-reported health status 28. Patient’s stated reason for visit or chief H (outpatient) complaint 9. Functional status 10. Years of schooling I chiefly responsible for services 29. Diagnosis provided G (outpatient) 11. Patient’s relationship to subscriber/person eligible for entitlement 30. Other G diagnosis (outpatient) 12. Current or most recent occupation and industry 32. Birth weight of newborn , 115 FIGURE 5-8 Core data elements recommended by NCVHS1. 31. External S cause of injury 13. Type of encounter 33. Principle procedure (inpatient) 14. Admission date (inpatient) 34. Other S procedures (inpatient) 15. Discharge date (inpatient) 35. Dates H of procedures (inpatient) 16. Date of encounter (outpatient and physician service) A and services (outpatient) 36. Procedures 17. Facility identification I of patient (inpatient) 38. Disposition 18. Type of facility/place of encounter C (outpatient) 39. Disposition 19. Health-care practitioner identification (outpatient) Q expected sources of payment 40. Patient’s 20. Provider location or address of encounter (outpatient) A charges 42. Total billed N prescribed 37. Medications 41. InjuryU related to employment 1 required, whereas others are optional. Two minimum standard data sets are compared in Figure 5-9. 1 Data elements entered into a computer system can be used in many different reports and 0 must rewrite the information in screens without reentering the data. A facility using paper forms the appropriate box on each different form. This is sometimes 5 avoided by preprinting a number of labels containing patient identification information, which can then be attached to blank forms, thus saving the time and reducing the possibility of errors. T In addition to the two data sets listed above, here is a more S complete list of standard data sets used in healthcare: 䊏 䊏 The Uniform Hospital Discharge Data Set (UHDDS) is used by acute care hospitals and required by CMS. The Uniform Ambulatory Care Data Set (UACDS) is used by ambulatory care facilities and required by CMS. 1 Core Health Data Elements Report: Report of the National Committee on Vital and Health Statistics (Washington, DC: National Committee on Vital and Health Statistics, August 1996). Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 116 8/10/09 9:53 AM Page 116 CHAPTER 5 UACDS Uniform Ambulatory Care Data Set UHDDS Uniform Hospital Discharge Data Set Patient identification Patient identification Residence Date of birth Date of birth Sex Sex Race and ethnic background Race and ethnic background Residence Living arrangement and marital status Health care facility identification number H I Provider Location or address G Provider Profession G S Date, place, and address of encounter , Patient’s reason for encounter Provider identification Problem, diagnosis, or assessment Admission Date Discharge Date Attending Physician Identification number Surgeon identification number Principal diagnosis S Other Diagnoses H Services Date and Principal procedure A Other Procedures and dates N Disposition Disposition of the patient at discharge I Expected sources of payment Expected sources of payment C Total charges Q FIGURE 5-9 Comparison of elements in ambulatory care and hospital U charge data sets2. A 䊏 䊏 䊏 䊏 䊏 䊏 The Uniform Clinical Data Set (UCDS) is used by quality improvement organizations and 1 in Medicare. required in hospitals that participate ® 1 Commission and is required for accreditation. It is ORYX was developed by the Joint used to measure performance and 0 outcomes. The Minimum Data Set (MDS) and the Resident Assessment Instrument (RAI) are used in 5 by CMS. long-term care facilities and required T The Outcome and Assessment Information Set (OASIS) is used by home health agencies and required by CMS. S The National Cancer Data Base (NCDB) is used by hospital cancer registries and required for accreditation. The Data Elements for Emergency Department Systems (DEEDS) is used by hospitalbased emergency departments. Its use is optional. 2 “Appendix VI: Report of the Subcommittee on Ambulatory Care Statistics and the Interagency Task Force on the Uniform Ambulatory Care Data Set,” in The National Committee on Vital and Health Statistics Annual Report, 1989, DHHS Publication No. (PHS) 90-1205 (Hyattsville, MD: National Center for Health Statistics, June 1990), 47–68. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:53 AM Page 117 HEALTHCARE RECORDS 䊏 䊏 117 The Health Plan Employer Data and Information System (HEDIS) is used by managed care plans and employer-sponsored plans to evaluate quality of care. Its use is optional. The Uniform Ambulatory Medical Care Minimum Data Set (UAMCMDS) has added some additional data elements to the UACDS. Its use is optional. Data sets originally developed for uniform paper forms are considered by many to be inadequate for electronic systems. Remember that in most cases these are the minimum sets of data and generally HIS application software uses a great many more data elements. Unfortunately, these additional elements are not necessarily standard across various systems. NCVHS and others have called for increased efforts to develop standardized data sets for an electronic environment.3 Policies and Procedures As important as having the right elements and data sets on the forms or in the database is knowing how and when they are to be used and by whom. To accomplish this, health information proH fessionals, hospital administration, and the medical staff establish policies and procedures to I meet documentation requirements. As we discussed in Chapter 2, a number of state and federal G regulations govern healthcare facilities. Among these regulations are requirements for minimum levels of documentation. G Accreditation organizations also have documentation requirements. Much of their audit process concerns determining if the facility’s standards are S sufficient and if those standards are being met. , Because significant overlap usually occurs among the documentation requirements of different regulatory agencies, various accrediting bodies, and the hospital’s own internal needs, healthcare organizations often develop policies that adhere to the strictest standards, thus S ensuring compliance with all documentation requirements. The facility’s policies concerning Hmedical staff and conforming to documentation are usually incorporated in the rules for the them becomes a condition for doctor’s hospital privileges. A AHIMA has developed the following documentation guidelines that apply to both paper and 4 N electronic health records: 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 Every healthcare organization should have policies that Iensure the uniformity of both the content and the format of the health record. C The policies should be based on all applicable accreditation standards, federal and state Q regulations, payer requirements, and professional practice standards. The health record should be organized systematically inU order to facilitate data retrieval and compilation. A Only individuals authorized by the organization’s policies should be allowed to enter documentation in the health record. The authors of all entries should be clearly identified in 1 the record. 1 Only abbreviations and symbols approved by the organization and/or medical staff rules and regulations should be used in the health record. 0 All entries in the health record should be permanent. 5 Errors in paper-based records should be corrected according to the following process: Draw a single line in ink through the incorrect entry. Then printTthe word “error” at the top of the entry along with a legal signature or initials; the date, time, S and reason for change; and the title and discipline of the individual making the correction. The correct information is then added to the entry. Errors must never be obliterated. The original entry should remain legible and the corrections should be entered in chronological order. Any late entries should be labeled as such. 3 Toward a National Health Information Infrastructure (Washington, DC: National Committee on Vital and Health Statistics, June 2000), www.ncvhs.hhs.gov/NHII2kReport.htm. 4 Smith, Cheryl M., “Documentation Requirements for the Acute Care Inpatient Record,” Journal of American Health Information Management (2001): 56A–56G. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 118 8/10/09 9:53 AM Page 118 CHAPTER 5 䊏 䊏 Any corrections or information added to the record by the patient should be inserted as an addendum (a separate note). No changes should be made in the original entries in the record. Any information added to the health record by the patient should be identified as an addendum. The HIM department should develop, implement, and evaluate policies and procedures related to the quantitative and qualitative analysis of health records. Continuity of Care Records One of the chief functions of the patient’s health record is as a communication tool among the various care providers serving the patient. As the patient moves through different areas of a facility (for example, admitting, radiology, surgery), providers record their findings, actions, and orders in the chart. As the patient isHseen subsequently by nurses, doctors, or therapists, each provider can read what the previous care workers have observed and what has been done. In this I way the health record serves to provide continuity of care for the patient. G notes from each visit, test results, and reports from conIn an outpatient setting, the progress sulting physicians and outside facilities are compiled into the patient’s health record or chart. G Because intervals of months or even a year between doctor visits are not uncommon, the patient’s record provides continuity of care S by enabling the clinician to review information about the patient’s previous visits and treatments. , In larger group practices, the patient may see different doctors on different visits. In those cases, the health record enables continuity of care among the providers. However, patients do not alwaysS go the same doctors, the same medical practice, nor use just one pharmacy. Thus, the patient’s health record becomes scattered among various facilities, with H is more the norm than the exception today and is one of no one having the complete record. This the contributing causes of medical errors. A The health system today is dependent on the patient’s ability to reliably tell each provider what has been done by other providers and what treatments N and medications have been prescribed. I C Several attempts have been made to ensure continuity of care when patients are treated at multiQ network or IDN was one. The IDN attempted to make ple facilities. The integrated delivery patient records available to providersUwho were members of a larger healthcare organization. In most cases these were medical practices, surgical facilities, and hospitals owned by a nonprofit A the patient was treated outside the network, the inforor for-profit corporation. However, when Regional Health Information Organization (RHIO) mation did not become part of the record. In 2004, President George W. Bush signed an executive order establishing the position of the 1 National Coordinator for Health Information Technology, to “develop, maintain, and direct the implementation of a strategic plan 1to guide the nationwide implementation of interoperable health information technology.”5 The purpose of the initiative is to eventually build a National 0 Health Information Network (NHIN). Although it may take considerable 5 time to create a true NHIN, many areas of the nation are attempting to create state or local versions. RHIO stands for regional health information T as a “neutral organization that adheres to a defined organization. HIMSS defines a RHIO governance structure which is composed of and facilitates collaboration among the stakeS holders in a given medical trading area, community or region through secure electronic health information exchange to advance the effective and efficient delivery of healthcare for individuals and communities.”6 RHIOs encourage the exchange of a patient’s health information across medical practices and facilities that are owned by different entities for the better well-being of the patient. The for- 5 President George W. Bush, Executive Order #13335, April 27, 2004. HIMSS RHIO Federation Definitions Workgroup, http://himss.org. 6 Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:53 AM Page 119 HEALTHCARE RECORDS 119 mation and operation of a RHIO must overcome numerous obstacles. These include technical, economic, and political issues: 䊏 䊏 Technical: Interfacing systems from different vendors in a hospital is not an easy task, but at least it is managed by one IT department and shares a common network. The level of difficulty becomes multiplied when unrelated hospitals and physician practices—each with numerous systems—attempt to translate data and share a common network. Economic: The translation of data from one system to another requires an interface engine and possibly a regional MPI. Who bears the cost of the networking, interface programming, and maintenance of the translation and MPI systems? Also, many RHIOs operate on a volunteer basis, but require a paid IT director, employed by the RHIO, not one of its members. H 䊏 Political: I Some participants in the RHIO are business competitors who may be leery about what data G or case mix, volume of busiis shared and whether it can be analyzed to reveal their patient ness, and so on. Additionally, state laws may affect whoG can participate in the RHIO and whether members can be in bordering states. Who Owns the Record? S , Historically, the provider, group practice, or facility considered itself to be the owner of a patient’s health record. HIPAA did not challenge that ownership but circumvented it by giving the patient specific rights. As we discussed in Chapter 3, under S HIPAA patients have the right to access their medical record, review it, request changes to inaccurate information, and obtain a H copy of their health record. While the privacy of a patient’s health record is fully protected in a RHIO, the question of A ownership becomes increasingly cloudy as information from multiple facilities becomes part of N the current provider’s record. I C For some patients the solution to having health records in multiple places is to maintain their Q have taken to carrying copies own. In paper-based systems, a few chronic or seriously ill patients of their own records from specialist to specialist, to ensure the Umost expedient care and avoid the long wait for paper records to be copied and transferred. Though most patients don’t go to this A extreme, the Internet may change that. The Personal Health Record A number of online services now offer patients the ability to maintain their own personal health record (PHR) online. The Internet services allow patients to log on to a secure website to create and update their records. The patient controls who has1the right to access the information and can add or remove permission for clinicians they might 1 visit to view the online record. The advantage of an online PHR is that is available everywhere. Wherever patients are traveling, if they need medical care, they can retrieve their own0records using the Internet. Another advantage is that the online record can integrate information5about visits to many different doctors or about medications purchased at several different pharmacies. The disadvantage is that in T most cases patients must enter the information themselves. A sample of a personal health record S is shown in Figure 5-10. Telemedicine Telemedicine uses communication technology to deliver medical care to a patient in another location. A consulting health professional studies the patient’s case and offers advice or instructions to the requesting physician or directly to the patient, neither of whom are at the consultant’s location. Telemedicine can take many forms, ranging from a simple phone call between two doctors to a videoconference. Even examinations or surgical procedures can be conducted remotely. Telemedicine can be practiced in real time or in a store-and-forward manner. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 120 8/10/09 9:53 AM Page 120 CHAPTER 5 FIGURE 5-10 Personal health record (Courtesy of Good Health Network, Inc.) H I G G S , S H A N I C Q Real-time telemedicine requires the presence of all parties at the same time, for example, a conference call. Store-and-forwardU telemedicine allows one party to send information that is saved and then reviewed and responded A to later. A simple analogy of store-and-forward telemed- icine would be voicemail. One doctor leaves a message stating the facts of the case; the other doctor listens to the message and then calls back, leaving a detailed response for the original doctor. In practice, however, telemedicine is1not that simple. When participants are located in different time zones, real-time telemedicine sessions can be 1 difficult to schedule. State laws can prohibit treatment of patients by providers licensed in another 0 state. Although store-and-forward telemedicine works well for consults, it can involve delays when additional information or tests are needed and one must wait for the response to arrive. Also, it is 5 not suitable to remote, robotic, or even guided surgery, all of which must be conducted in real time. T it makes high-level medical expertise available to remote The benefit of telemedicine is that and rural areas. Many communitiesS do not have medical specialists. Even fewer, places in the world have subspecialists, or sub-subspecialists who can recognize and treat rare or complex medical problems. Using telemedicine, it is possible for a local physician to get advice from a distant expert and guidance in treating the patient. Teleradiology Teleradiology is specifically concerned with the transmission of diagnostic images from one location to another. Usually this is for the purpose of having the images “read” by a radiologist at the receiving end. This may be to obtain a second opinion or consult, or because the sending facility does not have sufficient radiologists on staff and has contracted to have radiology interpretations done by another facility. In the latter case, state laws may require the radiologist to be licensed by the state from which the images are sent. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:53 AM Page 121 HEALTHCARE RECORDS 121 Patient Reporting and Telemonitors Many patients with chronic conditions are monitored at home using devices such as blood pressure monitors, glucose meters, and Holter monitors. Some of these devices store the readings and transfer the data to the doctor’s system either by using a modem and phone line or by downloading from the device during a patient encounter. For blood pressure monitoring, if the device does not store the readings, the patient may keep a log, which is then entered into the patient’s medical record at the doctor’s office. One example of a telemonitor is the Holter monitor, a device the patient wears for 24 to 72 hours to H measure and record information about the patient’s heart. The data is then transferred either remotely or I in person to the doctor’s computer where it is G reviewed. Figure 5-11 shows a patient wearing a Holter monitor. G When a patient is seen in a doctor’s office, meaS surements of vital signs, a glucose test, or even an ECG reflect only the patient’s condition at that particular time. , The advantage of telemonitoring is that it allows the provider to study these values measured many times over the course of the patient’s normal daily activity. S H One of the key technologies impacting our society is the Internet. It has changed the way people A changes in healthcare. While communicate, research, shop, and do business. It is also influencing the banking, brokerage/investing, and travel industries have Nmade Internet-based transactions readily available to consumers, healthcare as a whole has not. That seems to be changing. I offers interesting possibilities for One of the developments brought about by the Internet that enhancing the efficiency of providers and improving the quality C of healthcare for the patients is the E-visit. An E-visit allows the patient to be treated by a clinician for nonurgent health probQ lems without having to come into the office. Although communication between provider and patientU using e-mail is insecure or must be encrypted as required by HIPAA, an E-visit has advantages that e-mail lacks. Not only is the A message secure, but the E-visit gathers symptom and HPI information, creating a documented E-Visits FIGURE 5-11 An IQholter™ worn by the patient gathers cardio data. (Courtesy of Midmark Diagnostics Group.) medical record. When this information is integrated with the EHR, the E-visit becomes a part of the patient’s chart, just like any other visit. 1 Also, e-mail is sent to a particular individual and therefore not likely to be accessible by another provider. In contrast, E-visits can be handled by the “doctor on-call,” allowing practicing 1 partners to share E-visit duty, just like they share other on-call services. 0 Equally as important to the clinician, the E-visits are reimbursed as a legitimate visit by Blue 5 in some states. A study by Cross/Blue Shield plans and other private insurance carriers PricewaterhouseCoopers predicted that more than 20% of allT office visits could be replaced by an online equivalent by 2010.7 S To use E-visits, the patient must be an established patient with the practice whose medical records are on file. E-visits would not be appropriate for a new patient who has never been seen at the practice. Here is an example of the basic workflow of an E-visit: WORKFLOW OF AN E-VISIT 䊏 䊏 A patient accesses the physician’s website and signs on. The patient is already registered as an established patient of the practice. The patient answers a few simple questions and selects the reason for the visit from a list. From this information the software asks a set of questions appropriate to the complaint. 7 HealthCast 2010: Smaller World, Bigger Expectations (PricewaterhouseCoopers, November 1999). Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 122 8/10/09 9:53 AM Page 122 CHAPTER 5 A REAL-LIFE STORY Telemedicine at Mayo Clinics By Marvin P. Mitchell and Ron Rea Marvin P. Mitchell is the division chair of Media Support Services, Mayo Clinic, and Ron Rea is an analyst for Systems & Procedures, Mayo Clinic. Mayo Clinic is the largest and most prestigious not-for-profit group practice in the world. Its headquarters is in Rochester, Minnesota, with clinics in Jacksonville, Florida, and Scottsdale, Arizona. I send images in their original high-resolution form. It may take an think Mayo Clinic did its very first telemedicine consultation via satellite back in the 1960s as a demonstration project with Australia. When we opened our clinics in Jacksonville, Florida, in 1986 and Scottsdale, Arizona, in 1987 we got into it in a much bigger way. Our goal was to be able to provide all the services that the Mayo Clinic in Rochester, Minnesota, offers to all of our patients, regardless of whether they came to Rochester, Jacksonville, or Scottsdale. We put into place the best technology available in the 1980s. That was a very high resolution satellite broadcasting system equivalent to what they now have at NBC or CBS, but with the transmission encrypted for privacy and security. We had our first telemedicine consultation two days after Jacksonville opened their doors. We continued to do consultations by this method, but one area we struggled with was getting x-rays and larger diagnostic images to transmit with enough resolution for what we do. Our practice at Mayo is largely tertiary and quaternary care; that is, very sick patients who have already been to family physicians and specialists; they are coming here for a subspecialist or sub-subspecialist consultation. When you get to that level of care, the quality of imaging is absolutely critical. We eventually found that face-to-face consultations via television didn’t work very well. First, because there are a lot of things the consulting physician needs to go along with that: lab reports, diagnostic images, other examination records, and so forth. Second, it was disruptive to our physicians because they had to leave their practice and go to a special video studio. It was very difficult to get two or more physicians on the video link at the same time; if another opinion was needed, that specialist might not be available. So we began to phase the video out of telemedicine because it just wasn’t working and we began looking for a different approach. In 1996 we were approached by the UAE (United Arab Emirates) about doing telemedicine with their clinics. However, they were 10 time zones from Rochester, so doing real-time, faceto-face consultation would be almost impossible. Dr. George Gura (who is the medical director for the project) had the idea of creating a physician-to-physician, second-opinion service using what we call store-and-forward telemedicine. To use store-and-forward telemedicine, they package up the case with all its inherent images, lab data, history, demographics, and transmit it to Mayo. This allows us to use a data network to hour for the image to get here, but it is an absolute perfect image, H not like you would get shooting it with a video camera and sendIing them over video link. G The workflow is illustrated in Figure 5-12. The physician on the other end does the necessary examinations and tests they would G normally do. If at some point they determine that they need a subspecialty consult, they get high-resolution images, scanned paper S documents, motion image capture, angiography, and those types ,of things that they can generate on their end. That is packaged in an electronic format and transmitted with a consultation request to the Mayo telemedicine office. We tried to design a system that works as if the patient were here. If, when Mayo’s telemedicine office receives the electronic package, the patient has never been here before, we actually register this patient as though the person walked in the door. The patient is given a Mayo Clinic number and an electronic medical record is created. When a patient comes to a Mayo clinic, we assign a personal physician to handle the patient’s care; in most telemedicine cases that will be Dr. Gura. He will review the case and forward the information to the appropriate Mayo physician(s) following our processes here. For example, if they sent a CT scan, we actually create an order in the ordering system and the images are actually passed on to our PAC system for handling; a notification is sent to the techs to say there is a case waiting. They get the case up on the screen for the radiologist to view; the radiologist interprets it; dictates a report. Similarly with other specialties, neurology for example, they would look at the neurologist’s reports, they would look at other information that was sent, and they dictate their second opinion into our clinical notes system. If a surgical consult is needed those are done as well. When all the subspecialists’ reports have been completed, a second-opinion document is compiled from them and sent back to the physician who requested the consult. That physician then has a second opinion that can be worked into the diagnostic and treatment planning for the patient. A real-time interaction between the physicians is not necessary. One of the principal advantages of this workflow is that it is as transparent to the Mayo physicians as possible. They don’t have to learn a new system; they don’t have to change their practice model to accommodate telemedicine. They see the patient’s records in the same system they use everyday. S H A N I C Q U A 1 1 0 5 T S Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:53 AM Page 123 HEALTHCARE RECORDS Local physician MD initial exam 123 MD reviews clinical information Consultation Request Telemedicine office Tests Procedures and interpretations MD consults MD diagnosis/ treatment plans H I G G S opinion Second , Subspecialty interpretations Mayo Clinic e-consult service S Subspecialty H consults Report & A treatment Hospital options N returned I Home C Q U FIGURE 5-12 Workflow of the Mayo Clinic telemedicine system A Surgery CP1103574-20 (Courtesy of Mayo Clinic.) 1 advantage of keeping the patient’s home physician in control of the patient care at all times. 1 Telemedicine provides easy access to Mayo Clinic subspecialty 0 care. It is like adding 1,600 subspecialists to the hospital with very little impact to them. It has a positive impact on the patients, 5 improves the patient satisfaction with the hospitals, and avoids travel and costs. I think similar savings could be realT unnecessary ized using telemedicine more in the United States. S Mayo Clinic has a model of care that we try to adhere to at all One thing we require is that the physician on the other end ask a specific question, rather that ask for a general opinion. For example, “Is this Bell’s palsy? Has the patient had a stroke?” That way we can make sure we are targeting exactly what the physician needs. Mayo provides value to the requesting physician, because we do have that subspecialty expertise that they don’t. This solution also solves the problem of licensure that has hindered telemedicine in the United States. Currently, most states require a physician to be licensed by that state to treat patients in that state. The regulations apply to telemedicine as well. Therefore, either out-of-state patients must travel to Mayo or our doctor must hold licenses in multiple states. At Mayo, the telemedicine consultation is physician to physician; we are not giving advice to the patient, we are a resource for their doctor. Therefore, no laws are broken. This has the additional times; it is just how we practice medicine. Over time we felt that the store-and-forward model of telemedicine worked best with our Mayo model of care and its multi-specialty integration, how we treat patients when they come through in that multi-specialty environment, and being able to ask other colleagues. That works best with store-and-forward. It didn’t work well with video. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 124 8/10/09 9:53 AM Page 124 CHAPTER 5 䊏 䊏 䊏 䊏 䊏 The patient answers the questions and can add free-text clarification at various points in the interview. • E-visits are only used for nonurgent visits. If the condition seems urgent, the software advises the patient to seek immediate medical care and the provider is notified to determine the proper course of action. • If the software determines that the condition is not urgent but the patient needs to be seen in the office, the patient is given a message to that effect and automatically offered a choice of available appointments. When the interview is complete, the clinician is notified that an E-visit is ready to review. The clinician reviews the patient-entered data and any relevant patient medical records and then replies to the patient. The system allows the provider and patient to continue to exchange messages, much like a question-and-answer session in the exam room, except for the factor of time, which is sometimes H delayed by one or both parties’ responses. The clinician can also prescribe electronically during the E-visit just as he or she would during I the clinician’s reply to the E-visit, they are prompted to an office visit. When patients receive select their preferred pharmacy from G a list (if it is not already known to the EHR) and the prescription is electronically transmitted to the pharmacy by the doctor’s system. G The doctor’s response can also include patient education material and comments or care instructions from the doctor, allS of which are recorded in the care plan as well. , into the doctor’s EHR to become part of the patient’s Data from the E-visit can be merged medical record. The doctor’s practice management system can verify the patient eligibility for the E-visit and submit the claim electronically. S In an independent study sponsored by Blue Shield of California,8 most patients and doctors in the study preferred a web visit to H an office visit for nonurgent medical needs. Providers found that the E-visit gathered the important A details and eliminated multiple messages back and forth that occur when trying to provide patient care via e-mail. The patients found that the time spent N was eliminated with an E-visit. The reality of online scheduling, driving, parking, and waiting medical visits with your doctor is notI a question of if, but when. Chapter 5 Summary Understanding Healthcare Records Healthcare records have many purposes, the most important of which is the patient’s care. • The patient health record is the repository of data and information about a patient, the condition of the patient’s health, the care and treatments the patient received, and the outcome of that care. • The term patient health record has replaced the term patient medical record because it encompasses a holistic view of patient care. Though the terms are used almost interchangeably, an acute care patient record is usually concerned with one stay or episode, whereas an outpatient medical record is usually limited to one group or clinic. C Q U A • Data and information is not the same thing. Data are 1 records of facts. Information is data in a useful form that conveys meaning. 1 Functions of Healthcare Records 0 patient’s health record serves as the principal commu5• A nication document among various providers who might T care for the patient at different times in different departments. S• The patient record provides the basis for all billing and reimbursement. Medical claims will not be paid by an insurance company if the patient record does not have enough detail about the encounter or treatment to support the claim. 8 The RelayHealth Web Visit Study: Final Report (RelayHealth, January 2003), www.relayhealth.com. ©2002–2003 RelayHealth Corporation. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 8/10/09 9:53 AM Page 125 HEALTHCARE RECORDS 125 • The health record is a legal document; relevant porDemographic data is often gathered on paper forms, tions of the patient’s record may become evidence in a then transferred into the computer by the registration clerk. court of law. In a paper-based system, this principal document will be • Healthcare records provide the basis for improvements called a face sheet. In an electronic system, the forms may be in health. scanned into a document image system. Clinical data include documents created by the patient, • Individually, a patient’s record is evaluated and used nurses, clinicians, and other providers. Some standard types to develop care plans for the patient. of clinical documents include: • Collectively, health records can be used by a healthcare facility to improve the quality and processes of • Medical history healthcare delivery. • Physical exam • Public health departments, Homeland Security, and • Diagnostic and therapeutic orders law enforcement officials use information from health • Diagnostic and therapeutic reports records. • Diagnostic images • Researchers use patient records from clinical trials to H • Operative records monitor the effectiveness and safety of new drugs. I • Nursing notes • De-identified health records are analyzed by researchers consults G •• Referral to find health trends in our society and measure which Case management treatments seem to have the best outcomes. G • Discharge summary Obstetrical records S •• Pediatric records Primary and Secondary Records , • Problem list Health information professionals classify health records as • Medication list primary and secondary records: • Public health records. S • Primary records are those that are gathered directly from the patient and his or her providers and from H Documentation Standards devices and diagnostic tests. Primary records are used professionals seek to ensure uniform quality patient A HIM for patient care and as legal documents. records. Some of the ways to accomplish this are to use stan• Examples of primary records include admission N dardized data elements, data sets, and HIM policies and and discharge reports, nursing notes, physician I procedures. examinations and notes, all orders, test results, operative reports, pathology and radiology reports, C • Data elements define specific units of information that may consist of several fields. For example, the patient and administrative and demographic forms. Q name element would typically include first, middle, • Secondary records are those that are created later, by and last name and a suffix. analyzing, summarizing, or abstracting from the pri- U • Standard data sets are a collection of data elements mary records. Secondary records are used in billing, A determined to be the minimum necessary for a particuresearch, and quality improvement. lar purpose. • Examples of secondary records include insurance • HIM policies and procedures establish documenta1 claims, master patient index, and ALOS reports. tion requirements for health records and are typically included in the rules medical staff must follow. 1 Contents of Health Records 0 Patient health record data consists of administrative and demographic data and clinical data. Administrative data5 includes a number of legal documents signed by the patientT or their representative. These may include: • • • • • • • • • • HIPAA consent to use and disclose PHI Consent to treatment Medicare patient rights statement Assignment of benefits Informed consent Refusal of treatment Advance directives Organ donor Personal property list Disclosure records. S Continuity of Care Records Clinical data in the patient record helps provide a continuity of care as the patient is seen at different times by different healthcare workers. • In an inpatient facility, the patient moves through different departments of a facility, for example, admitting, radiology, or surgery. Because providers record their findings, actions, and orders in the chart, subsequent caregivers can read what the previous nurses, doctors, or therapists have observed and what has been done. • In an outpatient setting, a lapse of months or even a year between doctor visits is not uncommon. The exam notes from each visit, test results, and reports from consulting physicians and outside facilities are filed in Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M05_GART2674_01_SE_C05.QXD 126 8/10/09 9:53 AM Page 126 CHAPTER 5 the patient’s chart. This information about the patient’s previous visits and treatments enables the clinician to provide continuity of care over a longer period of time. However, because patients do not always go to the same doctors, the same medical practice, nor use just one pharmacy, a complete health record for the patient does not exist in any one place. A regional health information organization (RHIO) is one way for different providers to share patient records. One issue for a RHIO is who owns the data? Historically, the provider, group practice, or facility considered itself to be the owner of a patient’s health record, but information sent via a RHIO is merged into the receiving facility’s patient records, clouding the issue. Though the provider owns the patient record, HIPAA gives patients the right to review, copy, and amend their health record. Patients are also creating personal health records through neutral online entities that allow them to make their records available to different providers they visit. Telemedicine Telemedicine uses communication technology to deliver medical care to a patient in another location. Telemedicine can provide high-level medical expertise to remote and rural areas. Telemedicine can be practiced in real time or in a storeand-forward manner. • Real-time telemedicine requires the presence of all parties at the same time, for example, a conference call. • Store-and-forward telemedicine allows one party to send information that is saved and then reviewed and responded to later. Teleradiology is telemedicine specifically concerned with the transmission of diagnostic images from one location to another. Usually this is for the purpose of having the images “read” by a radiologist at the receiving end. H Telemonitoring allows doctors to study vital signs or tests measured many times in the course of the patient’s norImal daily activity using devices such as blood pressure monitors, G glucose meters, and Holter monitors. The devices store the readings and transfer the data to the doctor’s system G either by using a modem and phone line or by downloading from S the device during a patient encounter. E-visits are being used in some states to allow the ,patient to be treated by a clinician for nonurgent health problems without having to come into the office. E-visits are conducted over the Internet. S H A Critical Thinking Exercises N 1. CMS takes the position that “if it isn’t documented, it wasn’t done.” What does this mean and why would it matterI to CMS? 2. Chapters 4 and 5 discussed data C sets. Design a basic demographic data set. Make a list of just the fields you would need for the patient information. (You do not need to Q include insurance information.) U A Testing Your Knowledge of Chapter 5 1. Health records are classified as primary or secondary records. Give an example of each type. 2. List two ways in which healthcare records provide the basis for improvements in health. 3. Provide an example of patient health record data that is administrative or demographic data. 4. Provide two examples of types of clinical data in a patient’s chart. 5. What is a RHIO? 6. What are some differences between the contents of patient records at an inpatient facility versus a doctor’s office? 7. What does the acronym PHR stand for? 8. There are two methods of telemedicine. Which method is used by the Mayo Clinic? 1 19. Describe the difference between a data element and a data set. 0 10. How do HIM policies and procedures help ensure qual5 ity patient records? T11. Name three functions of patient health records. 12. The patient record provides the basis for all billing and S reimbursement. What will happen if the patient record does not have enough detail? 13. What is the difference between data and information? 14. Provide an example of how the patient record helps provide continuity of care. 15. What is an E-visit? Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. Instructions: This assignment must be done in APA format. A minimum word count of 300 words (not including references) is required. A minimum of 3 references (with in-text citations) is required. Please make sure that scholarly references are used. If you have any questions please feel free to ask. 1. Health records are classified as primary or secondary records. Give an example of each type. Also, and analyze two ways in which healthcare records provide the basis for improvements in health. Offer at least one current institution using this as a best practice. Finally, provide an example of patient health record data that is administrative or demographic data. Be specific. https://www.beckershospitalreview.com/hospital-managementadministration/10-statistics-your-hospital-should-track.html Additional information about EHR problems : https://thehealthcareblog.com/blog/2018/04/07/how-to-fix-the-electronichealth-record/ Book Reference: Gartee, R. (2011). Health information technologyand management. Upper Saddle River, NJ: Pearson. Instructors Notes: • • In professional writing avoid using first person “I” and third person “we”, as they detract from the quality and turn professional researched statements into opinions. Instead of “I” use, for example, use “the writer, the author or the researcher”. Approved sources for this course include the course textbook and scholarly articles from the Bethel library databases. No other source information is acceptable.
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