With the emphasis today on accurate MDS coding, proper reimbursement, and complete and timely documentation, having an effective and ef-ficient Health Information Management (HIM) department in every long-term care (LTC) 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), a registered health information administrator (RHIA), or is simply non-credentialed, proper training on HIM policies and procedures, 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, 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 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 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.” Continuous monitoring of 15- and 22-day audits ensures follow-up for missing documentation and provides accurate and complete documentation.
Readmission 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 by more than 30 days. Use this information in your facility's QAA meetings to initiate a plan of correction (POC).
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 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 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.