Health Records in Other SettingsAmbulatory Care Rehabilitation

Long Term Care Home Care

Mental Health

Hospice

Why There are Differences The type of setting

The type of services

The type of patients served

Differences External factors

JCAHO Other regulatory bodies that may accredit a

facility State and local laws Rules that apply to facilities that receive funding

from the federal government

Similarities All facilities should document to

Ensure continuity of care Justify reimbursement Protect the facility or the patient in legal

proceedings Contribute to research and education

Emergency Room Records Documentation is limited to information

about the patient’s presenting problem

Important to document: Instructions given to patient Patients presenting complaint Evaluation Assessment

Emergency Room Records

See list of standard information required, text book page 73

Ambulatory Care Many forms are similar to those used in

hospitals Unique to ambulatory care may be:

Problem list Medications list Patient history questionnaire

Usually the patient fills out a history form themselves. In the hospital the physician does this.

Ambulatory Surgery Records

Very similar to records in a hospital-based surgery department

Ambulatory Surgery Records Medicare requires

Patient ID History & Physical Preoperative studies Findings and techniques of the operation

including pathology reports

Ambulatory Surgery Records Medicare requirements, cont…

Allergies and abnormal drug reactions Record of anesthesia administered Informed consent to treatment Discharge diagnosis

Ambulatory Surgery Records Should also include documentation of:

The patient’s course in the recovery room

Routine follow-up phone call or visit

Long Term Care (LTC) The regulations that govern long term care

facilities have established strict documentation standards Most are governed by both federal and state

regulations Most do not participate in voluntary accreditation

processes

Long Term Care Records are based upon ongoing assessments

and reassessments of the patient’s needs RAPS – Resident Assessment Protocols

The health care team develops a plan of care for each patient and the plan is regularly updated

Long Term Care Resident Assessment Instrument (RAI) is the

format for the care plan that is required by federal regulations

The plan is reassessed on a quarterly and annual basis and whenever there is a significant change in patient’s condition

The RAI is a critical component of the health record

Long Term Care MDS – Minimum Data Set

Medicare form used to determine Medicare reimbursement

Many states also use it to determine Medicaid reimbursement

Accreditors or licensors use the information during the survey process

Long Term Care Centers for Medicare and Medicaid Services

(CMS, formerly HCFA) uses MDS data to compile information on demographics and quality indicators

Feedback is provided to each family

Long Term Care Unique to LTC is that most documentation is done

by nurses and other health care providers rather than physicians

Physician develops the plan of treatment

Physician visits patient on a 30-60 day schedule and reviews treatment plan and makes updates/orders as needed

Home Health Care (HHC) Huge growth in this area

Patient’s desire to be at home for as long as possible has fueled this industry

Cost savings as compared to residential facilities

Home Health Care Medicare regulations and accreditation

standards have established documentation requirements

Mandate periodic assessments Plan of Care is a central component of

documentation Plan of Care is established by the physician

ordering treatment

Home Health Care Plan of Care

Physician must renew plan every 60 days Updates can be made by telephone orders from

physician Physician visits in the home are not required Patients may be required to visit the physician

Home Health Care OASIS

Outcomes and Assessment Information Set Medicare form Standardized assessment form Foundation for the plan of care Basis for Medicare reimbursement Submitted electronically to CMS

Home Health Care Unique to home care is a service agreement

Details the type and frequency of services, the charge for the services, and the parties responsible for payment

Home Health Care Documentation depends on the services

ordered Each visit must be documented Challenge of maintaining records when

caregivers are not in a central location Some parts of the record may be kept in

patient’s home to allow for effective communication between caregivers

Home Health Care Record maintenance issues

How do documents get to main office? How often? Who tracks this?

Security issues Care providers driving from home to home with

confidential documentation in their car Electronic record would be ideal

Home Health Care

See list of other typical documentation, in text book page 78

Hospice Basic ID date Plan of Care and documentation of care given Palliative care

Keeping the patient comfortable and as pain free as possible

Care plan is reviewed every 30 days Federal regulations and accreditation

standards guide hospice documentation

Hospice Care continues even after death of patient

Follows the family through the bereavement process and can last as long as one year

Behavioral Health Care Mental Health Delivered in a variety of settings

Inpatient hospitals Outpatient clinics Rehabilitation programs Community mental health programs

Behavioral Health Care Documentation requirements differ in each

setting See the minimum documentation

requirements unique to the behavioral health setting established by JCAHO on page 79 of text book

Rehabilitation Services Health record documentation reflects the level

of care provided

CARF – Commission on Accreditation of Rehabilitation Facilities The accreditation body for rehabilitation facilities

CARF requires a record for each patient

Rehabilitation Services Evaluations and recertifications every 30-60

days Often have to be mailed to physician for signature

See documentation requirements on page 80 of text book

Job Preparation As long as you know “the basics” and can

transfer that knowledge to the different types of facilities, you will be able understand and adapt to the health information systems at different types of facilities