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

Practice Guidelines for LTC Health Information and Record Systems


Filing and Retrieval


HIM STANDARDS:

  • The healthcare organization’s and health information management department’s filing systems, whether paper   based, hybrid or fully electronic, policies and procedures comply with federal and state regulations and accepted standards of practice to ensure that all health records and resident-identifiable data are well organized and readily available for resident care, research, education, and other authorized uses.
  • Policies and procedures exist to facilitate the prompt, consistent, uniform, and efficient filing of all health records and resident-identifiable data.
  • The filing system is designed and implemented to ensure the safety, security, and accuracy of health records and resident-identifiable data.
  • Policies and procedures exist to facilitate the prompt, consistent, uniform, and efficient retrieval of all health records and resident-identifiable data, and the policies and procedures ensure that confidentiality is maintained and that retrieval is performed only by authorized persons.
  • The retrieval system is designed and implemented to ensure that safety, security, and accuracy of health records and resident-identifiable data.
  • Every long term care facility should have an established a system for filing and retrieving of their health records. The sophistication of the filing system is dependent on the volume of filing, admissions, discharges, and requests for records. Only trained staff should have access to the records and perform the filing and retrieval functions.

Retrieval

Paper Based System 
During normal business hours requests for thinned or discharged health records should be coordinated through the HIM staff.

It is recommended that a process be in place to track the locations and holders of the health record. This can be accomplished through a record check out system.  A reasonable length of time should be identified for which a record can be checked out. 

Hybrid or Electronic System 
Appropriate access levels should be given based on the needs of the staff member to perform their job.  Completed records upon discharge would be locked and only available as read-only.  There should be a limited number of staff members with printing capabilities. 

After Hours Retrieval – Paper Based System 
Every facility should have a process in place for after hour retrieval of records in case of an emergency.  Because evening and night shift staff may have to complete deficient discharge records or have access to an overflow record, the supervisor should have keys to access the department and be trained in retrieval, the sign-out process, and other security measures.  Department procedures should track who has keys to the department and documentation of their training on filing and retrieval procedures.

After Hours Retrieval – Hybrid or Electronic System 
If using a hybrid or electronic health record consider if parts of the electronic health record need to be printed during the duration of the stay or upon discharge.   This will depend on how the health record is defined within the organization and electronic storage capabilities.

Filing

Paper based system 
Filing of all documents that should be part of the complete health record are added to the discharge record, preferably prior to completion.  As with the addition of any document to the record, care should be taken to verify the resident name prior to inserting the document in the record. 

Hybrid system 
The facility policies and procedures should determine which parts of the record will be paper based and which parts are stored in a data repository.  This policy should also determine whether or not additional documents should be added as paper based documents or scanned into the data repository. If documents are added to the electronic portion of the record after this has been completed, these should be added as addendums. Refer to section 4.1 Table 1 Legal Source Legend for the hybrid record. 

Electronic record 
The facility policies and procedures should allow for the capture of additional material for the electronic record through a system of scanning to the file.  If the record has been determined to be complete and additional paperwork is discovered, these documents should be added as addendums.

Separate Location for Incomplete Records

Paper Based System
It is recommended that incomplete paper based health records be kept in a separate location in the department rather than integrated with all of the discharge medical records.  An incomplete record area facilitates ease in retrieval for staff responsible for completing records and also provides for easier monitoring of incomplete records.

Hybrid or Electronic System
If the health record is hybrid or fully electronic, it is recommended that a method be developed to flag incomplete records and determine access to such records.  Polices and procedures should also be developed to identify how e-signatures will effect your processing.  Determine if the vendor can help with automating the deficiency analysis along with ensuring the application can monitor and track, records or document completion.

If using a hybrid or electronic health record consider if parts of the electronic health record need to be printed during the duration of the stay or upon discharge.  This will depend on how the health record is defined within the organization and electronic storage capabilities.  Refer to section 4.1 Table 1 Legal Source Legend for the hybrid record.

Typical Filing Systems

Paper Based System
There are many acceptable methods for filing health records ranging from the simple (alphabetical to the complex (terminal digit filing).  The resident record can also be filed by room number on each unit for active residents.  The type of system selected is based on facility-specific factors such as the volume of filing, admissions, discharges, requests for records, filing space, storage (open shelf filing vs. file cabinets) and security concerns.

The following are the most common filing systems used in long term care for overflow records and discharge records.  Overflow records are filed alphabetically, with all forms organized in reverse chronological order based on the facility’s active chart order.  Overflow files can be subdivided with chart dividers to facilitate efficient file and retrieval of information   Subdividing the overflow files also enhances record assembly upon discharge.

Discharge records are filed alphabetically by discharge year.  This method is commonly used when there is limited space in the health information department to retain more than one year of discharge records.  Alphabetic filing provides the easiest method for retrieval of records.  Special systems are not required to locate a resident’s record.  This method offers the least security since anyone can locate a resident record.  However, with proper security of locking doors and/or file cabinets which house the records, this system allows for the most efficient system for retention and ultimate destruction of records as records can be boxed by year and removed.

Discharge records are filed alphabetically with multiple years integrated together.  A color-coded label is placed on the tab of the folder to indicate the discharge year. When there is adequate storage in the health information department, multiple years of records are integrated and filed alphabetically.  This method does require some movement of the records to allow for adequate space of filing additional records within the existing system.

Discharge records are filed numerically by health record number by discharge year.  Records are filed by health record number in numeric order for a single discharge year.  This method offers better security than alphabetic filing because the health record number must be known to a record.  Access is more difficult for supervisory staff who must access records when the health information department is closed.  A color-coded label is placed on the tab of the folder to indicate the discharge year.  Multiple years of discharges are integrated together and filed by health record number when there is more filing space in the health information office.

Hybrid System
When a medical record is both paper based and electronic combined, the policies and procedures should reflect the parts of the record stored in each medium.  Also, the policies and procedures should reflect which documents should be scanned for inclusion in the electronic portion of the record prior to completion.  If a portion of the record is paper based, a reference to the location of the electronic portion should be added to this chart.  (Refer to section 4.1 Table 1 - Legal Source Legend for the hybrid record.)

Electronic Record
The fully electronic record would be available in a variety of formats.  The electronic system should be able to separate the active from the inactive record within the data base.

Retrieval

Paper Based System
During normal business hours requests for thinned or discharged health records should be coordinated through the HIM staff.

It is recommended that a process be in place to track the locations and holders of the health record. This can be accomplished through a record check out system.  A reasonable length of time should be identified for which a record can be checked out.

Hybrid or Electronic System
Appropriate access levels should be given based on the needs of the staff member to perform their job.  Completed records upon discharge would be locked and only available as read-only.  There should be a limited number of staff members with printing capabilities.

After Hours Retrieval – Paper Based System
Every facility should have a process in place for after hour retrieval of records in case of an emergency.  Because evening and night shift staff may have to complete deficient discharge records or have access to an overflow record, the supervisor should have keys to access the department and be trained in retrieval, the sign-out process, and other security measures.  Department procedures should track who has keys to the department and documentation of their training on filing and retrieval procedures.

After Hours Retrieval – Hybrid or Electronic System
If using a hybrid or electronic health record consider if parts of the electronic health record need to be printed during the duration of the stay or upon discharge.  This will depend on how the health record is defined within the organization and electronic storage capabilities.

Filing

Paper based system
Filing of all documents that should be part of the complete health record are added to the discharge record, preferably prior to completion.  As with the addition of any document to the record, care should be taken to verify the resident name prior to inserting the document in the record.

Hybrid system
The facility policies and procedures should determine which parts of the record will be paper based and which parts are stored in a data repository.  This policy should also determine whether or not additional documents should be added as paper based documents or scanned into the data repository. If documents are added to the electronic portion of the record after this has been completed, these should be added as addendums. Refer to section 4.1 Table 1 Legal Source Legend for the hybrid record.

Electronic record
The facility policies and procedures should allow for the capture of additional material for the electronic record through a system of scanning to the file.  If the record has been determined to be complete and additional paperwork is discovered, these documents should be added as addendums.


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