The importance of a Health Information Management department: HIM staff can expedite key audits for better reimbursement and quality.With the emphasis today on accurate MDS MDS,
n See temporomandibular pain-dysfunction syndrome.
MDS 1 Maternal deprivation syndrome, see there 2 Myelodysplastic syndrome, see there coding, proper reimbursement Reimbursement
Payment made to someone for out-of-pocket expenses has incurred. , and complete and timely documentation, having an effective and efficient Health Information Management (HIM) department in every long-term care long-term care (LTC),
n the provision of medical, social, and personal care services on a recurring or continuing basis to persons with chronic physical or mental disorders. (LTC LTC
lieutenant colonel ) facility is more vital than ever. These HIM staff members need specific training, of course. Regardless of whether the HIM employee is a registered health information technician (RHIT RHIT Registered Health Information Technician ), a registered health information administrator (RHIA RHIA Registered Health Information Administrator (formerly Registered Records Administrator; American Health Information Management Association) ), or is simply non-credentialed, proper training on HIM policies and procedures Policies and Procedures are a set of documents that describe an organization's policies for operation and the procedures necessary to fulfill the policies. They are often initiated because of some external requirement, such as environmental compliance or other governmental , specific duties, and relevant regulations is necessary for the department to be effective and meet facility goals.
Specific HIM Department Tasks
In addition to typical medical record duties, every HIM coordinator should be conducting chart audits and Quality Assurance Assessments (QAAs). Reviewing the chart for content, completion, and timeliness of documentation is crucial to the facility's operation. Chart documentation supports the quality of care provided, and medical record audits ensure that all care and services were rendered as ordered. Your HIM coordinator should complete two types of audits: qualitative and quantitative.
* Qualitative audits look at the quality of documentation based on clinical practice guidelines clinical practice guidelines Clinical policies, practice guidelines, practice parameters, practice policies Medtalk Systematically developed statements to assist practitioner and Pt decisions about appropriate health care for specific clinical circumstances. See Psychology. , compliance with regulations, and standards of practice. The auditor focuses on a cause-and-effect relationship and whether the proper services and care were rendered. A HIM consultant or staff member who has professional experience and education in HIM usually does this audit.
* Quantitative audits are more general and basic, focusing on whether the documentation is complete. The auditor basically answers "yes" or "no" without looking for Looking for
In the context of general equities, this describing a buy interest in which a dealer is asked to offer stock, often involving a capital commitment. Antithesis of in touch with. a cause-and-effect relationship. Current HIM staff, including non-credentialed coordinators, can be trained to perform this type of audit.
When Should Staff Audit a Chart?
Audit charts of new admissions, readmissions, and active (in-house) residents. As residents experience a significant change in condition, audits can reflect this change and the auditor can verify that appropriate documentation is present. With all the various audits performed, it is essential that staff use an audit sheet that correlates with the type of chart audit being done. Audit sheets should include all federal and state regulations, as well as your facility policies and procedures. Facilities can develop their own sheets or rely on a HIM consultant to develop them. The completed audits sheets can and should be used in the QAA QAA Quality Assurance Agency for Higher Education (UK)
QAA Questions and Answers
QAA Quality Assurance Assessment
QAA Quality Assurance Audit
QAA Quality Assurance Analyst
QAA Quality Assessment Audit (USACE) program.
New admission audits. Staff should conduct a chart audit within 24-72 hours of a resident's admission. This ensures that a complete and accurate chart is prepared right from the start. Monitoring the chart helps staff to document from day one appropriate care plan goals and interventions. Staff should be able to open the chart and read the documentation like a "picture-perfect storybook sto·ry·book
A book containing a collection of stories, usually for children.
Occurring in or resembling the style or content of a storybook: storybook characters; a storybook romance. ." Continuous monitoring of 15-and 22-day audits ensures follow-up for missing documentation and provides accurate and complete documentation.
Readmission readmission Managed care The admission of a Pt to a health care facility for a condition–eg, stroke, MI, GI bleeding, hip fracture, cancer surgery, shortly after discharge. See nth admission. Cf Admission, Discharge. audits. If a resident is transferred to the hospital and returns to the facility, staff should audit readmission documentation similar to the new admit audit.
Discharge audits. The assembly and analysis of a discharge record is extremely important in long-term care. This process allows a complete audit of required documentation before the medical record is filed. Once the resident is permanently discharged from the facility, the HIM coordinator should audit the chart within three to five days and complete and file discharge records within 30 days of the discharge date unless state laws define a different time frame. The HIM coordinator should report records that are delinquent delinquent 1) adj. not paid in full amount or on time. 2) n. short for an underage violator of the law as in juvenile delinquent.
DELINQUENT, civil law. He who has been guilty of some crime, offence or failure of duty. by more than 30 days. Use this information in your facility's QAA meetings to initiate a plan of correction (POC (Proof Of Concept) See PoC exploit.
POC - Point Of Contact ).
Quarterly in-house audits. To ensure that charts remain compliant with regulations and facility policy throughout residents' stay, the HIM coordinator should perform quarterly audits on all residents in the facility. These are done in conjunction with the MDS/care conference schedule. HIM staff should assign audits using an audit tool five to seven days after the scheduled care conference. At this time, staff should thin the chart to remove documentation that has already been used for the completion of the MDS. Ongoing monitoring and thinning of the chart on a quarterly basis will ensure an accurate, efficient, and compliant record.
The audit tool reflects specific information that the HIM coordinator checks. For example: Is the MDS completed per policy and regulation? Do the interdisciplinary in·ter·dis·ci·pli·nar·y
Of, relating to, or involving two or more academic disciplines that are usually considered distinct.
Adjective staff complete documentation as required?
Incorporating HIM Tasks Into Your QAA Program
To have an effective QAA program, concerns or problems identified in the facility should be used to develop appropriate POCs. HIM audits can be a useful tool for this. If your facility has a credentialed cre·den·tial
1. That which entitles one to confidence, credit, or authority.
2. credentials Evidence or testimonials concerning one's right to credit, confidence, or authority: employee with professional training and experience in handling HIM tasks, this person will monitor, implement, and design appropriate POCs for trends and patterns identified from chart audits, and serve as a member of your QAA committee. If your facility does not have a credentialed employee in HIM, a HIM consultant can train and educate staff on appropriate audits and QAA reporting.
The Link Between Audits and Surveys
As a HIM consultant, I am constantly reviewing charts and performing audits using the above-mentioned audit tools. Credentialed or non-credentialed staff in the LTC facility can use similar audit tools, such as admission, active, and discharge. These can figure in as part of an effective POC for QAA purposes and, with the emphasis that surveyors place on QAA programs, staff can use audits to demonstrate facility compliance and proactive monitoring. The facility can also show audit trends and patterns and report a POC monthly.
The HIM coordinator must always communicate chart audit findings with the facility administrator and DON. This open communication will help to eliminate surprises at survey time. If staff conducts timely audits, the facility can initiate appropriate POCs before the annual survey.
When to Hire a HIM Consultant
AHIM consultant experienced in long-term care provides a facility with professional expertise and recommendations in HIM systems, medical record processing, documentation regulations, and training of new HIM staff, as well as provides assistance with monitoring. HIM consultants can also conduct mock surveys, set up or reorganize re·or·gan·ize
v. re·or·gan·ized, re·or·gan·iz·ing, re·or·gan·iz·es
To organize again or anew.
To undergo or effect changes in organization. the HIM department, and serve as members of QAA committees.
In any event, LTC facilities should use HIM staff to provide efficient, high-quality audits. HIM staff have much to offer that will prove beneficial to the facility.
Anissa McBreen, RHIT, is an independent consultant for long-term care facilities long-term care facility
See skilled nursing facility. , specializing in Health Information Management. For more information, phone (513) 260-7915. To send your comments to the author and editors, please e-mail firstname.lastname@example.org.
BY ANISSA MCBREEN, RHIT