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


Health Information Consultant Services


A health information consultant in long term care provides a facility or corporate office with professional expertise on health information, medical records, and documentation based on their education, skills and experience. At a time in the industry when quality of documentation for survey and litigation, coding, confidentiality and security are emerging as critical issues, the consultant is an invaluable resource for a facility. Consultants provide assistance with monitoring potential fraud and abuse issues, assistance with corporate compliance plans, and evaluation of documentation that supports the billing process.

By federal law, facilities are required to provide services that maintain the professional standards of practice. Many States have statutes that specifically require that facilities maintain the services of a consultant – check with your state to determine whether a consultant is mandated.

The section will assist in addressing expectations, performance standards, and utilization of a consultant. The information can be used both by a facility and a consultant to evaluate the quality of the services provided and make changes as necessary. This document is meant to provide a consistent set of expectations and deliverables to assure that both facilities and consultants have a common vision of role and services of a consultant. The specific types of functions and the role of a consultant are outlined here.

A consultant is often contracted independently with a facility to provide professional expertise in coordination with a non-credentialed practitioner. However, many facilities utilize consultants to augment the services of a credentialed health information practitioner by providing independent audits and assessing the quality of documentation, the adherence to legal and regulatory documentation standards and billing support. In addition, many facilities utilize consultants for inservices and training programs.

Frequency of Consultant Visits

The role and functions of a consultant should be tailored to the needs of each facility. This chart provides guidelines to align expectations with a recommended frequency for visits, but would not prevent a consultant and facility from mutually agreeing upon other functions during a visit. The frequency of consulting visits that a facility is looking for should directly correlate to responsibility and role of the consultant.

Frequency of Visits

General expectations for the role of Consultant

Monthly or More Often

Oversight of HIM department to include health information system evaluation, implementation, and monitoring, policy and procedures, assessment and monitoring of documentation; monitoring QI’s, training and inservicing, input into facility QA Committee; assistance with billing and compliance issues, assistance with implementing new systems. The hours budgeted each month must provide the consultant with adequate time to complete the functions listed.

Quarterly or Semi-Monthly

Assess basic HIM functions and monitors status of key areas in the department – provide new information and spot checking, some troubleshooting of problems/ issues with minimal follow-up; minimal audits – not proactive; minimal on-going monitoring; deals with problems identified by facility and HIM department; focus is on a few key areas with facility to follow-up; training or inservices as recommended by facility; Typically quarterly visits are full day visits regardless of size of facility.

Semiannually or
Annually

*Generally not recommended

Brief look at the general systems and department functions. No oversight or monitoring of department functions. Address issues identified by the facility. Minimal to no audits. If audits done they would be few in number to provide a snapshot but not representative of facility documentation practices with a comprehensive list of problem areas. Facility may request inservice or training based on problems that they have identified. Typically visits are full days regardless of size of facility.

Focus Review or PRN Visits

Functions performed specific to the need identified by the facility or per contract. Generally no oversight or monitoring of HIM functions.

Recommended Number Of Visits:

The number of visits should be decided between the consultant and the facility, however, monthly visits are recommended to get the oversight of HIM systems including the department, documentation, quality indicators, coding/reimbursement and compliance. At a minimum it is recommended that facilities contract for no less than quarterly visits.

The factors that should be considered when deciding on a visit frequency including the bed size of the facility, availability of a corporate health information consultant, state regulations requiring specific HIM services, crisis situations or survey/quality indicator problems, staff turnover, and the performance or expertise of HIM staff.

Indicators for Increase in Consulting Visits:

There are times when an increase in consultation visits may be warranted. The following indicators provide a good rule of thumb to consider additional hours or warrant a focus review. The number of extra visits are variable based on the severity of the problems identified.

  • Turnover in health information coordinator position requiring training of new staff. The number of additional visits will vary based on the past experience and performance of the new coordinator hired.        
  • Survey or quality indicator problems related to quality of care and documentation. Consultants can provide tailored documentation audits, inservices, and plans to assist in analyzing and correcting a problem.
  • Reimbursement, coding or corporate compliance issues such as an increase in the number of denials by the fiscal intermediary. Focus audits can help to identify and correct a documentation problem.
  •   Program changes such as a change in licensure status, new accreditation status (JCAHO), or certification status (NF to SNF).
  • Extraneous training needs based on findings from the facility.
  • New major regulations or initiatives such as HIPAA, computerization initiatives, etc. that have an impact on health information systems, documentation or reimbursement.  

Performance Expectations for a Consultant

  • PROFESSIONALISM: Possess knowledge and understanding of current issues affecting long term care facilities. Possess good communication skills with the ability to establish rapport and motivate staff through positive interaction.
  • CONSULTATION REPORT: A type written, professional report is delivered in a timely manner after the consultation visit unless other arrangements are made with the facility. A process should be in place to follow up on past recommendations. (See Content of Consultation Reports for more details).
  • INITIAL EVALUATION: When first contracting with a facility, a consultant should complete a comprehensive evaluation. It is preferred that the consultant have an evaluation checklist such as one published in the Health Information Management Standards of Practice published by AHIMA.
  • WORK PLAN: A work plan should be developed for the facility which identifies the areas to be evaluated, when they were evaluated, and when follow-up should occur. It is recommended that a work plan be developed for a calendar year. Developing a work plan can help in managing the expectations of the facility with the number of hours contracted. Set clear expectations with regard to hours available. Clarify facility goals and crosscheck against budgeted hours.
  • ENTRANCE CONFERENCE: An entrance conference should be conducted with facility staff to discuss and communicate the work plan for the day. The plan for the day should be agreed upon mutually by the facility and consultant. The consultant should adjust his or her work plan to accommodate facility needs.
  • EXIT CONFERENCE: An exit conference should be held with the appropriate staff (such as administration and other staff administration would like to have present). It may not always be appropriate to have an exit conference with all staff mentioned depending on the sensitivity of the information to be discussed.
  • SCHEDULING VISITS: Consultation visits should be scheduled in advance during the working hours of the health information coordinator and administration.
  • PROFESSIONALISM: Consultants should be professional in dress and attitude.
  • CONTRACT HOURS: Meet assigned contract hours unless an change in the schedule is mutually agreed upon.
  • PROFESSIONALISM: Possess knowledge and understanding of current issues affecting long term care facilities. Possess good communication skills with the ability to establish rapport and motivate staff through positive interaction.
  • CONSULTATION REPORT: A type written, professional report is delivered in a timely manner after the consultation visit unless other arrangements are made with the facility. A process should be in place to follow up on past recommendations. (See Content of Consultation Reports for more details).
  • INITIAL EVALUATION: When first contracting with a facility, a consultant should complete a comprehensive evaluation. It is preferred that the consultant have an evaluation checklist such as one published in the Health Information Management Standards of Practice published by AHIMA.
  • WORK PLAN: A work plan should be developed for the facility which identifies the areas to be evaluated, when they were evaluated, and when follow-up should occur. It is recommended that a work plan be developed for a calendar year. Developing a work plan can help in managing the expectations of the facility with the number of hours contracted. Set clear expectations with regard to hours available. Clarify facility goals and crosscheck against budgeted hours.
  • ENTRANCE CONFERENCE: An entrance conference should be conducted with facility staff to discuss and communicate the work plan for the day. The plan for the day should be agreed upon mutually by the facility and consultant. The consultant should adjust his or her work plan to accommodate facility needs.
  • EXIT CONFERENCE: An exit conference should be held with the appropriate staff (such as administration and other staff administration would like to have present). It may not always be appropriate to have an exit conference with all staff mentioned depending on the sensitivity of the information to be discussed.
  • SCHEDULING VISITS: Consultation visits should be scheduled in advance during the working hours of the health information coordinator and administration.
  • PROFESSIONALISM: Consultants should be professional in dress and attitude.
  • CONTRACT HOURS: Meet assigned contract hours unless an change in the schedule is mutually agreed upon.
  • MAINTENANCE OF A CONTRACT: A written contract should signed by both the consultant and the facility. The contract should include the number of hours or visit schedule agreed upon, the scope of services to be provided, the hourly rates and expenses to be charged by the consultant. The contract should contain language that protects the confidentiality of the consultation reports from discovery (i.e. litigation purposes) by placing the report under the quality assurance program. As an example, the following statement could be used: As part of {facility name} Quality Assurance Program, {consultant name} has been retained to provide oversight of the facility health information systems, conduct audits, etc. {tailor role based on functions performed}. Any reports shall be part of the facility quality assurance documents and considered confidential.
  • WORK WITH CORPORATE AND FACILITY POLICIES: A consultant should be mindful of corporate policies related to HIM and assist the facility in adhering to those policies and procedures. If the consultant recommends changes in corporate policy/procedures and the facility concurs, a written report should be made to the corporate contact person with suggested alternatives and valid reasons.
  • EVALUATION OF CONSULTANT SERVICES: On a routine basis (i.e. annually) the consultant and facility administrator should evaluate the consultant services. A formal mechanism such as a survey sent by the consultant or in a face to face meeting with the facility administrator or their designee can be conducted. (See Evaluating Consulting Services)
  • ABILITY TO ASSESS THE QUALITY OF DOCUMENTATION: It is critical that a consultant have the ability to assess the quality of documentation across all disciplines. To do so, the consultant must understand the regulations, clinical standards, legal issues, reimbursement methods and have the ability to apply them to a variety of situations.
  • PROVIDE TELEPHONE CONSULTATION: Because not all problems can wait until the next consultation visit, the consultant should provide telephone or e-mail consultation as situations arise. Telephone consultation time is equivalent to on-site consultation time. The facility should expect to pay for the time it takes to answer the questions that arise between consultation visits.

Consultation Reports

Consultation reports should be provided after each visit to summarize the activities, findings and recommendations. There may be times when the consultant is working on an on-going project in which a written report after each visit is not necessary, but a summary is expected at the end of the project. The consultant and administrator/designee should decide on the expectations for a written report prior to the start of the project.

Timeliness of Consultation Reports

Timely, complete and accurate consultant’s report are a valuable tool for follow-up and monitoring by a facility or corporation. The quality of a consulting service is equally dependent on the quality, content and timeliness of the written report provided after the consultation. A report is considered timely if it is provided to the facility within 7 to 10 working days after the consultation visit was conducted.

It is an advantage for the consultant and the facility to have a report or an abstract/draft report of activities, findings and recommendations prior to leaving the facility on the day of a visit. With the use of laptops or pre-printed reporting worksheets, a consultant should strive to provide some documentation on the day of the visit before leaving the facility.

Content of Consultation Reports

  1. Demographics: Each consultation report should include the following basic information: Name and address of the facility, date of consultation visit, and consultants name, credentials and title.
  2. Statement of Activities: It is suggested to start a report with a concise statement of the activities performed during the consultation visit. This can be in the form of a brief narrative summary, bulleted list or a pre-printed checklist form with activities identified. This summary will give the administrator a document that can be reviewed and summarized quickly.
  3. Summary of Findings, Recommendations, and Follow-up: Provide a written summary of key findings, recommendations and follow-up activities or direction necessary. It is not necessary to describe every activity performed during the visit, but to focus on the key findings in which there are recommendations and/or follow-up. The report should direct the facility and provide guidance on what the facility is to do -- an action plan format may work well for this section of the report. The report should be written in language that is understandable to the reader.
  4. Attachments or Appendixes: This section should include either a copy of the audit tools or a summary of the audit findings and any copies of resources provided such as forms, regulations, etc.
  5. Report Footer: A statement such as the following should be included in the consultation report to protect the confidentiality of the consultation report and audit findings. As part of {facility name} Quality Assurance Program, {consultant name} has been retained to provide oversight of the facility health information systems, conduct audits, etc. {tailor role based on functions performed}. Any reports shall be part of the facility quality assurance documents and considered confidential.

If the facility or corporation requests a specific format or specific forms for the consultation report, their request should be accommodated if possible.

Note: When summarizing audits of patient records, the patient name should not be included in the report. The medical record number should be referenced.

Distribution of the Consultation Report

Upon initiation of the contract, the consultant and administrator should decide to whom the consultant’s reports should be sent. It is often necessary to send two copies of the report – one to the administration/director of nursing services and one to the health information coordinator.

If the corporate office requests copies of reports to assist in their monitoring of the HIM problem areas, a copy of the report should be sent to the appropriate corporate person.

Retention of Reports (Facility And Consultant)

As a general rule, facilities should retain the consultation reports for a minimum of 2 years unless state law or corporate policy specifies a different time frame. Consultants should retain a copy of their reports for a minimum of 7 years or the state-specific statute of limitations for business records.

Evaluating Consulting Services

To assure that the customer (the facility or corporation) is satisfied with the services provided, it is recommended that a consultant incorporate some type of formal evaluation for feedback from the client. Feedback is essential to maintaining, improving , and growing a consulting business. One possible method would be to send out a questionnaire on an annual basis evaluating the services that they are providing. If the consultant does not have a process, the facility administrator should implement an evaluation and discuss their comments with the consultant during a consultation visit.

Sample 1: Consulting Service Evaluation:


The following questionnaire provides a baseline for an evaluation of services.

  1. In general, do you feel that the services provided by your consultant have been helpful?:
    __ Strongly Agree __ Agree __ No Opinion __ Disagree __ Strongly Disagree
    Comments:
  2. Are the reports your receive helpful?
    __ Strongly Agree __ Agree __ No Opinion __ Disagree __ Strongly Disagree
    Comments:
  3. Are the reports you receive understandable?
    __ Strongly Agree __ Agree __ No Opinion __ Disagree __ Strongly Disagree
    Comments:
  4. Are the reports you receive returned promptly?
    __ Strongly Agree __ Agree __ No Opinion __ Disagree __ Strongly Disagree
    Comments:
  5. Do you feel that the frequency of on-site visits are made regularly and as needed according to contract?
    __ Strongly Agree __ Agree __ No Opinion __ Disagree __ Strongly Disagree
    Comments:
  6. Do you feel there is good rapport and communications between the consultant and your staff?
    __Yes __No
    Comments:
  7. Do you feel that the entrance and exit conference with each visit is:
    __Beneficial __Not Beneficial
    If not, why?
    Comments:
  8. If asked, would you recommend this consultant to other long term care facilities?
    __Yes __No
    If not, please explain:
    Comments:
  9. Do you feel that the consultant keeps you up to date with changes and brings new ideas to your facility? __Yes __No

Comments:

Recommendations for Improvement:

General Comments:


Sample 2: Consulting Service Evaluation:


Use the following scale to rate your health information consulting services in the past year.

Scoring:

Excellent = 4 Good = 3 Fair = 2 Poor = 1 Not Applicable = N/A

(Circle the score. Please provide comments and suggestions if score is less than three.)

1.    Provides quality training and direction to the health information designee.
Score:     4    3    2    1    N/A
Comments:

2.    Assesses the quality of the health information designee's job duties and makes recommendations.
Score:     4    3    2    1    N/A
Comments:

3.    Keeps us informed of new regulations and provides updates.
Score:     4    3    2    1    N/A
Comments:

4.    Provides "quality" inservices to meet our needs.
Score:     4    3    2    1    N/A
Comments:

5.    Identifies and prioritizes problem areas for action (identifies our strengths and weaknesses).
Score:     4    3    2    1    N/A
Comments:

6.    Written reports clearly identify problems.
Score:     4    3    2    1    N/A
Comments:

7.    Written reports include realistic recommendations directed to solve identified problems.
Score:     4    3    2    1    N/A
Comments:

8.    Consultant reports are timely.
Score:     4    3    2    1    N/A
Comments:

9.    Follows up on prior reports.
Score:     4    3    2    1    N/A
Comments:

10.    Assists during survey and with plan of correction if requested.
Score:     4    3    2    1    N/A
Comments:

11.    Exits with Administrator/Director of Nursing Services.
Score:     4    3    2    1    N/A
Comments:

12.    Health Information Department policy and procedure manual is rated as:
Score:     4    3    2    1    N/A
Comments:

13.    I have a good rapport with my consultant.
Score:     4    3    2    1    N/A
Comments:

14.    Consultant keeps appointments timely.
Score:     4    3    2    1    N/A
Comments:

15.    Overall rating of medical records consulting services.
Score:     4    3    2    1    N/A

Comments:

General Comments, strengths and suggestions:


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