3. Name and discuss the various categories of medical facilities. Provide local examples if possible (examples within your state if not).(reading attached)4. What is the purpose(s) the health record? Also, identify what your role as an HIM professional is for ensuring the quality of health record attributes. (reading attached)5. Compare and contrast and the paper-based & the electronic health record (EHR). Be sure to include the benefits and detriments.(reading attached)200 words per question
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Lesson
Introduction
Prior to the implementation of the inpatient prospective payment system (IPPS), patients characteristically
received health care services as hospital inpatients where they remained until they were well enough to be
discharged home. The IPPS uses diagnosis-related groups (DRGs) to categorize inpatient hospital cases into
groups that are anticipated to consume similar hospital resources. Medicare initially introduced this
classification system to pay for inpatient hospital care, with other payers adopting this PPS in succeeding
years. Under DRGs, inpatients are discharged after the acute phase of illness has passed, and they are often
transferred to other types of healthcare facilities. The transfer facilities provide an apt level of health care in
a safe and cost-effective way after the patient’s attending physician with the assistance of case managers
has determined which facility is best by assessing the patient’s medical condition, special needs, and
treatment objectives.
Health Care Settings
Most inpatient stays are typically short (less than 30 days) at acute care facilities (ACF). They provide
health care services to patients who have serious, sudden, or acute illnesses or injuries and/or who need
certain surgeries. Although some patients may stay for longer periods of time if it is medically necessary,
because each inpatient day is very expensive, a utilization manager closely monitors patient care to
determine whether acute health care services should be continued. Hospitals are classified as (1) single
hospitals (not part of a larger organization) and (2) multi-hospital systems (two or more hospitals owned,
managed, or leased by a single organization).
Other classification schemes include population served, bed size, and length of stay. Some health care
facilities provide care to specific groups of people. Some facilities focus on the treatment of children (e.g.,
pediatric hospitals) while others have special units (e.g., burn unit). The hospital bed size (or bed count) is
the overall number of inpatient beds for which the facility is licensed by the state; the hospital must be
equipped and staffed to care for these patient admissions. The hospital’s mean length of stay (LOS)
indicates whether the hospital stay is classified as short-term or acute, with an average LOS of 4 to 5 days
and a total LOS of less than 25 days, or long-term, with an average LOS of greater than 25 days.
Hospitals are also classified by the following types:
Critical access hospitals (CAH) are those located more than 35 miles from any other hospital or another
CAH, or they are state certified as being a necessary provider of health care to area residents. CAHs are
required to provide emergency services 24 hours a day and maintain no more than 15 inpatient beds.
General hospitals provide emergency care, perform general surgery, and admit patients for an array of
problems based on licensing by the state. Rehabilitation hospitals admit patients who are diagnosed with
trauma (e.g., broken leg) or disease (e.g., hypertension) and need to learn how to function. Behavioral
health care hospitals provide treatment for individuals with mental health diagnoses.
Hospital Patients
Hospital patients may classified as ambulatory patients (outpatients), ambulatory surgery patients (e.g.,
day surgery), emergency care patients, inpatients, newborn patients, observation care patients, and subacute care patients. The maximum length of stay is of 23 hours, 59 minutes, and 59 seconds for
ambulatory patients (or outpatients). They must be admitted to the facility as an inpatient if they require a
longer stay. Emergency care patients are treated for urgent problems (e.g., trauma) and are either
released the same day or admitted to the hospital as inpatients. Inpatients are provided with room and
board and nursing services for 24 or more hours.
Sub-acute Care
Sub-acute care is given in facilities that provide specialized long-term acute care such as chemotherapy,
injury rehabilitation, ventilator support, and wound care etc. These facilities can appear like mini-intensive
care units as they typically do not offer the full range of health care services available in acute care facilities
such as emergency departments, obstetrics, and surgery. Sub-acute care is much less expensive than acute
care, and patients are frequently transferred directly from an intensive care unit. Medicare will reimburse
sub-acute care facilities if care provided is applicable and medically necessary.
Managed care initially referred to the prepaid health care sector (e.g., HMOs), which combined health care
delivery with the financing of health care services. The term is progressively being used to refer to preferred
provider organizations (PPOs) and some forms of indemnity coverage or plans that allow you to direct your
own health care and visit almost any doctor or hospital you like, that incorporates utilization management
activities. Utilization management controls health care costs and the quality of health care by evaluating
cases for suitability and medical necessity. Preadmission certification (PAC) is a form of utilization
management that involves analysis for medical necessity of inpatient care prior to inpatient admission.
Some types of managed care include HMO, PPO, and EPO. Health Maintenance Organizations (HMO) provide
comprehensive health care services to members on a prepaid basis. A preferred provider organization (PPO)
is a network of physicians and hospitals join together to contract with third-party payers (e.g., insurance
companies), employers, and other organizations to provide health care to subscribers for a discounted fee.
Exclusive Provider Organization (EPO) affords benefits to subscribers who receive health care services from
network providers, which are physicians and healthcare organizations under contract to the managed care
plan.
Federal, State, and Local Health Care
Federal, state, and local correctional facilities afford inmates with a secure housing environment that also
offers medical, dental, and mental health care services. The standard of care provided to inmates is
imposed by court decisions, legislation, accepted correctional and health care standards, and departmental
policies and procedures. Care is provided by skilled healthcare professionals who are licensed by the state.
The Military Health System (MHS) governs health care for active members of the uniformed services (and
their dependents) as provided by military treatment facilities and networks of civilian health care
professionals. A military treatment facility (MTF) is a clinic and/or hospital located on a United States
military base. The Military Medical Support Office (MMSO) coordinates civilian health care services when MTF
services are inaccessible.
The Veterans Health Administration (VHA) provides medical, surgical, and rehabilitative care to veterans of
the armed services. The Veterans Health Administration is home to the United States’ largest cohesive
health care system consisting of 150 medical centers, nearly 1,400 community-based outpatient clinics,
community living centers, Vet Centers and Domiciliaries. The VHA developed regional Veterans Integrated
Service Networks (VISN) to administer and provide health care services at VA medical centers (VAMCs) and
community-based outpatient clinics.
The Administration for Children and Families (ACF) promotes the economic and social well-being of families,
children, individuals and communities. There programs include Temporary Assistance to Needy Families
(TANF), which provides grant funds to states and territories to provide families with financial assistance and
related support services, Administration on Aging (AoA), which promotes the well-being of older individuals
by providing services and programs designed to help them live independently in their homes and
communities and the Agency for Healthcare Research and Quality (AHRQ) supports research designed to
improve the outcomes and quality of health care, reduce its costs, address patient safety and medical
errors, and broaden access to effective services. Other nation-wide agencies involved in healthcare include
the Centers for Disease Control and Prevention (CDC), which provides a system of health surveillance to
monitor and prevent outbreak of diseases, the Food and Drug Administration (FDA) assures the safety of
foods and cosmetics, and the safety and efficacy of pharmaceuticals, biological products, and medical
devices, the Health Resources and Services Administration (HRSA) which oversees the nation’s organ
transplantation system and the Indian Health Service (IHS) which supports a network of 37 hospitals, 60
health centers, 3 school health centers, 46 health stations, and 34 urban Indian health centers to provide
services to nearly 1.5 million.
Preceding 1983, when the diagnosis-related groups (DRGs) prospective payment system (PPS) was
employed as part of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), patients usually received
health care services as hospital inpatients until they were well enough to be discharged home. Diagnosisrelated groups (DRGs) categorize inpatient hospital cases into groups that are likely to consume similar
hospital resources. Medicare initially introduced this classification system to pay for inpatient hospital care,
with other payers adopting this PPS in succeeding years. Under DRGs, inpatients are discharged once the
acute phase of illness has ended, and they are often transferred to other types of health care such as
outpatient care skilled care facilities, rehabilitation hospitals, home health care, etc. The transfer facilities
deliver an suitable level of health care in a safe and economical manner after the patient’s attending
physician (with the assistance of discharge planners, case managers, social workers, nurses, and others)
has determined which facility is best by assessing the patient’s medical condition, special needs, and
treatment objectives.
References
Skurka, M. A. (Ed.). (2017). Health information management: principles and organization for health information services. San Francisco,
CA: John Wiley & Sons.
LaTour, K. (2013). Health information management: Concepts, principles, and practice (4th ed.). Chicago,
IL: AHIMA.
McWay, D. (2014). Today’s health information management: An integrated approach (2nd ed.).
Clifton Park, NY: Delmar/Cengage Learning.
Sayles, N. (n.d.). Health information management technology: An applied approach (4th ed.).
Chicago, IL: AHIMA.

Lesson
Introduction
The patient record, weather paper or electronic, has many purposes, but only one objective —documentation of patient
care. It is a business record and serves as legal evidence of what has of the treatment and procedures the patient
receives. Irrespective of the treatment(s) provided, a health care facility’s patient records contain comparable content
(e.g., consent forms) and format features (e.g., all records contain patient identification information).
Definition of Purpose of the Patient Record
The health record functions as the business record for a patient encounter, contains
documentation of all health care services provided to a patient, and is a repository of information
that includes demographic data, as well as documentation to support diagnoses, justify treatment,
and record treatment results.
Demographic data is patient identification information collected according to facility policy and
includes the patient’s name and other information, such as date of birth, place of birth, mother’s
maiden name, social security number, and so on. In addition, the facility includes its name,
mailing address, and telephone number on each page of the patient record since providers who
receive copies of records may need to contact the facility for clarification about record content.
It is important to note that each page of the patient record should include the following
identification information: name of the attending or primary care provider, patient’s name, patient
number, date of admission/visit, and name/address/telephone number of the facility.
Ownership of the Patient Record
A lot of patient’s make the mistake of thinking the medical record is theirs. However, the medical record is the
property of the healthcare provider, and as governed by federal and state laws, the patient has the right to access its
contents for review (e.g., third-party payer reimbursement) and to request that erroneous information be amended. (If
the provider decides not to amend the record, the patient can pen a letter clarifying the information, which is then filed
in the record.) In addition, the provider has the option to keep the record on its premises or at a suitable off-site
storage facility. Electronic health records (EHRs) or computer-based patient records (CPRs) include electronic and/or
digital characters and signatures that are eternally stored on a disk; the records are viewed on a monitor or as a
printout. The provider is liable for keeping minimum data elements of authoritative original EHRs (or CPRs) in the same
manner as original paper records.
Authentication of Patient Record Entries
All patient record entries must be authenticated. Authentication means an entry is signed by the author (e.g.,
provider). Only the author of an entry can authenticate that entry, thus establishing that the entry is correct and has
been verified by the author. Authentication of patient record entries can be done through an author-entered computer
code. It is important to note, auto-authentication involves a provider authenticating a dictated report prior to its
transcription. Each health care facility must choose suitable authentication method(s), which comply with federal,
state, and/or third-party payer requirements. Methods include:
Signature Requirements for Patient Records
Healthcare organizations must require providers sign with their first initial, last name, and title/credential or discipline
as a minimum. A facility can have stricter minimums. Medicare requires a legible identity for services provided and
ordered but does not stipulate the technique to be used.
Electronic Signatures
As allowed by federal and state regulations, electronic signatures can be accepted by facilities. An electronic signature
is a nonspecific term for all the various methods by which an electronic document can be authenticated. They include
typing the name at the end of an email, inserting a digitized image of a handwritten signature in an electronic
document and a secret code or PIN (personal identification number) to identify the sender to the recipient. Similar to
an electronic signature is a digital signature. A digital signature is created using public key cryptography to
authenticate a document or message.
Signature Stamps
Signature stamps can be used by facilities if allowed by state and federal law. When signature stamps are used the
provider whose signature the stamp represents must sign a statement that she or he alone will use the stamp to
authenticate documents. The statement is kept on file in healthcare organization’s permanent files.
Abbreviations Used in the Patient Record
Every health care facility should establish a policy as to which abbreviations, acronyms, and symbols can be
documented in the patient record. The facility should maintain an official abbreviation list , which includes medical
staff–approved abbreviations, acronyms, and symbols (and their meanings) that can be documented in patient
records. Figure 4–7 provides an example of an excerpt from an abbreviation list. When more than one meaning exists
for an abbreviation, acronym, or symbol, the facility should prohibit its use.
Timeliness of Patient Record Entries
Entries in the patient record should be documented as soon as possible after care is provided so as to increase
accuracy of information recorded. Medicare Conditions of Participation (CoP) for Hospitals that require a complete
physical examination to be performed no more than seven days prior to admission or within 24 hours after admission.
The CoP stipulates that the report of physical examination must be placed in the patient record within 48 hours after
admission. The Joint Commission requires the history and physical examination to be documented in the patient record
within 24 hours of inpatient admission. The Joint Commission requires patient records to be completed 30 days after
the patient is discharged, at which time they become delinquent records.
Amending the Patient Record
Occasionally, it is necessary to correct the documentation in the health record. This is called amending the patient
record. The author of the original entry is only person authorized to correct an entry. The correct procedure for
amending an entry in a manual patient record is:
1. Draw a single line through the incorrect information, making sure that the original entry remains legible.
2. Date, specify time, and sign the corrected entry.
3. Indicate a reason for the error in a location as close to the original documentation as possible
Electronic health record systems should store both the original and corrected entry as well as a record of who
documented each entry. The date, time, and authentication of the person making the correction should be preserved
as well as the purpose for the change. Most electronic health record systems will generate a list of all changes made to
the health record in the form of an audit trail. The audit trail also contains the date, time, and user who performed the
transaction.
Patient Record Formats
Many organizations still maintain paper health records. Formats for maintaining paper health records include source
oriented record (SOR), problem oriented record (POR), and integrated record. Source oriented record (SOR) maintains
reports according to source of information. Lawrence Weed created the problem oriented medical record (POMR), now
called the problem oriented record (POR), in the 1960s to improve organization of the health record. The problem
oriented record (POR) consists of four components. Those components are the database, the problem list, the initial
plan and progress notes.
The database contains a minimum set of data to be collected on every patient, such as chief complaint; present
conditions and diagnoses; social data; past, personal, medical, and social history; review of systems; physical
examination; and baseline laboratory data. The problem list is filed at the beginning of the record and contains a list of
the patient’s problems. The initial plan is the strategy for management of the patient’s care. In a POR, each patient is
assigned one or more problems and notes are documented for each problem using the SOAP structure:
Subjective (S) —patient’s statement about how she feels, including symptomatic information (e.g., headache)
Objective (O) —observations about the patient, such as physical findings or lab or X-ray results (e.g., chest Xray negative)
Assessment (A) —judgment, opinion, or evaluation made by the health care provider (e.g., acute migraine)
Plan (P) —diagnostic, therapeutic, and educational plans to resolve the problems (e.g., patient to take Tylenol
as needed for pain)
Within an integrated record reports are arranged in strict chronological order. This format allows for observation of how
the patient is progressing throughout the continuum of care. It is easy to use, all information on an episode of care is
filed together and it is less time-consuming to file reports.
References
Skurka, M. A. (Ed.). (2017). Health information management: principles and organization for health information services.
San Francisco, CA: John Wiley & Sons.
LaTour, K. (2013). Health information management: Concepts, principles, and practice (4th ed.). Chicago,
IL: AHIMA.
McWay, D. (2014). Today’s health information management: An integrated approach …
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