AHIMA's Long-Term Care Health Information Practice & Documentation Guidelines

Please note: Portions of these guidelines are under revision to reflect regulatory and practice changes.

• Purpose and Use of These Guidelines
• Transition from Medical Records to Health Information (HIM)
• Definition of Long Term Care Facility
• Acknowledgements
• Copyright and Use of Report
• Reference to HIM Practice Standards

• Job Qualification, Responsibilities, and Functions of Health Information Staff in a LTC Facility
  • Role of the Credentialed Consultant
  • Role of the Credentialed Practitioner Working in a Long Term Care Facility
  • Role of the Non-Credentialed Practitioner Working in a Long Term Care Facility
  • Role of the Health Unit Coordinator
  • Evolving Role of Health Information
  • Frequency of Consultant Visits
  • Performance Expectations for a Consultant
  • Consultation Reports
    • Timeliness of Consultation Reports
    • Content of Consultation Reports
    • Distribution of Consultation Reports
    • Retention (Facility and Consultant)
    • Record Systems, Organization and Maintenance
      • Maintaining a Unit Record
      • Assigning a Medical Record Number
      • Maintaining Records in a Continuum of Care
      • Defining What is Part of the Medical Record
      • Maintenance of the Chart
      • Identification/Name and Medical Record Number on Pages
      • Common Chart Forms and Thinning Guidelines
        • Integrating Hospital Records into the Long Term Care Record
        • Thinning the Medical Record
        • Qualitative vs. Quantitative Audits and Monitoring
        • Assessing the Quality of Documentation
        • Routine Audits/Monitoring (Criteria and Timeframes)
        • Focus Audits and Monitoring Systems
        • Integrating Audits/Monitoring into the QA/QI Program
        • Retention of Audits, Checklists, and Monitoring Record
        • Auditing the Electronic Health Record
        • Discharge Record Assembly
        • Discharge Record Analysis
        • Timely Completion of a Discharge Record
        • Incomplete and Delinquent Records
        • Maintaining a Control Log for Discharge Records
        • When to Close a Record on Temporary Absence
          • Closing Records with a Change in Level of Care
          • Closing Records with a Payer Change
          • Separate Location for Incomplete Records
          • Typical Filing Systems
          • After Hours Retrieval
          • Storage System Options
          • Security Issues: Locking Office and Storage Areas
          • Alternative Storage Areas
          • Retention Guidelines
          • Acceptable Methods of Destruction
          • Abstracting Documents Prior to Discharge
          • Destruction Logs and Witnesses
          • Maintaining a Record Checkout System
          • What To Do If a Record Is Lost, Destroyed or Stolen
          • Disaster Plans
          • Identification of Confidential vs. Non-Confidential Information
          • Resident Access to Their Records
          • Confidentiality, Training and Agreements with Employees and Volunteers
          • Resident Identification Boards at Nursing Stations
          • Maintaining an Access/Disclosure Grid for Employees, Contractors and Outside Parties
          • Handling a Request for Medical Records
            • Review of Authorization for Release of Information
            • Preparing a Record for Release
            • Turn Around Time for Responding to a Request for Copies of Medical Records
            • Copy Fees for Release of Information
            • Documenting the Release of Information (Accounting of Disclosures)
            • Redisclosure Upon Transfer to Another Healthcare Facility
            • Training and Resources
            • Frequency of ICD-9-CM Coding
            • Coding and Billing Relationships
            • Investigation of Claim Rejection/Denials Due to Coding
            • Coding Issues Under Consolidated Billing
            • Master Patient Index
              • Maintaining an MPI
              • Minimum Content
              • Total Admissions
              • Total Discharges
              • Average Daily Census
              • Total Census Days
              • Length of Stay
              • Percentage of Occupancy
              • Purpose and Definition of the Legal Medical Record
              • Legal Documentation Standards
                • Defining Who May Document in the Medical Record
                • Linking Each Entry to the Patient
                • Date and Time on Entries
                  • Timeliness of Entries
                  • Pre-dating and Back-dating
                  • Signature
                  • Countersignatures
                  • Initials
                  • Fax Signatures
                  • Electronic/Digital Signatures
                  • Rubber Stamp Signatures
                  • Authenticating Documents with Multiple Sections or Completed by Multiple Individuals
                  • Printers
                  • Fax Copies
                  • Photo Copies
                  • Carbon Copy Paper (NCR)
                  • Use of Labels in the Medical Record
                  • Proper Error Correction Procedure
                  • Handling Omissions in Documentation
                    • Making a Late Entry
                    • Entering an Addendum
                    • Entering a Clarification
                    • Federal Regulations Pertaining to Clinical Records
                    • Purpose of the Documentation
                    • Elimination of Duplication/Redundant Information when Evaluating/Implementing a Documentation System
                    • Documentation Content in a Long Term Care Record
                      • Admission Record
                      • Integrating Assessments with RAI Process
                      • Types of Assessments and Requirements
                        • Preadmission Assessment
                        • Admission Assessment
                        • Fall Assessment
                        • Skin Assessment
                        • Bowel and Bladder Assessment
                        • Physical Restraint Assessment
                        • Self-Administration of Medication
                        • Nutrition Assessment
                        • Activities/Recreation/Leisure Interest Assessment
                        • Social Service
                        • Mental and Psychosocial Functioning
                        • Restorative/Rehab Nursing Assessment
                        • Rehabilitation Services
                        • Timeliness
                        • Care Conference
                        • Admission/Interim Care Plan
                        • Integrating Acute Problems Into the Care Plan
                        • Timeliness of Completion of Care Plan
                        • Authenticating Changes to Care Plan
                        • Admission/Readmission Note
                        • Content of Narrative Charting
                        • Monthly Summary Charting
                        • Integrated vs. Disciplinary Progress Notes
                        • Skilled Nursing/Therapy Charting
                        • Supporting Documentation for the MDS
                        • Therapy Treatment Time
                        • ADL Charting
                        • Mood and Behavior Documentation
                        • Hospital Documentation
                        • Medicare Certification/Recertification
                        • Physician Progress Notes
                        • Dictated Progress Notes
                        • NP/PA Documentation
                        • History and Physical
                        • Other Professional and Consultation Records/Notes
                        • Documenting Resident Diagnoses
                          • Supporting Documentation for Diagnoses
                          • Resolving Diagnoses
                          • Admission Orders
                          • Content of an Order
                          • Physician Order Recaps/Renewals
                          • Telephone Orders
                          • Fax Orders
                          • Standing Order Policies
                          • Authentication/Obtaining Signatures
                          • Transcription of Orders and Noting Orders
                          • Contacting the Physician to Obtain an Order
                          • Discontinuing an Order When a New Order is Obtained
                          • Updating/Changing Physician Order Recaps/Renewals After They Have Been Signed
                          • Processing Physician Orders After Hospitalization "Resume all Previous Orders"
                          • Verification of Hospital Orders with Attending Physician
                          • Accepting Orders From a NP/PA
                          • Accepting Orders from Specialists or Consultants
                          • Dose Reduction Schedules and Documentation
                          • Starting new Medication/Treatment Records Upon Readmission/Hospital Return
                          • Service Delivery Records
                          • Other Clinical Flow Records
                          • Informed Consent for Use of a Restraint
                          • Consent, Notice and Authorization to Use/Release Clinical Records
                          • Notice of Bedhold Policy and Readmission
                          • Notice of Legal Rights and Services
                          • Notice Before Transfer
                          • Notice Prior to Change of Room or Roommate
                          • DNR Order vs. Advance Directives
                          • Discharge Order
                          • Discharge Note
                          • Discharge Summary
                          • Transfer Form
                          • Physician’s Discharge Summary vs. Discharge Record

                          Copyright ©2014 American Health Information Management Association. All rights reserved. All contents, including images and graphics, on this Web site are copyrighted by AHIMA unless otherwise noted. You must obtain permission to reproduce any information, graphics, or images from this site. You do not need to obtain permission to cite, reference, or briefly quote this material as long as proper citation of the source of the information is made. Please contact Publications to obtain permission. Please include the title and URL of the content you wish to reprint in your request.