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

Practice Guidelines for LTC Health Information and Record Systems


Record Systems, Organization and Maintenance


A medical record must be maintained for every resident in a long term care facility. It is critical that every facility have formalized systems in place for the maintenance of records that are systematically organized and readily accessible.  With long term care providers at varying stages of automating their clinical documentation, there may be some portions of a record maintained electronically and some in paper format. This section of the report will deal with maintenance of the paper medical record and special considerations related to maintenance of electronic or hybrid records.

A hybrid record is a system with functional components that include both paper and electronic documents and use both manual and electronic processes. Software products, as well as human and fiscal resources of a facility, vary in the ability to implement and support a fully electronic health record (EHR).  Facilities can migrate to an EHR by staggering the automation of various components of the clinical record, such as the MDS, care plan or physician orders, while maintaining the remainder of the record in a paper format.  Fully automating a component of clinical documentation entails not only creating the information electronically, but the ability to:

  • electronically authenticate, correct, retrieve, and archive the information, 
  • destroy the electronic information in accordance with record retention policies,
  • produce hardcopy output of the electronic information as necessary for litigation or other warranted use, and

  • adhere to federal and state requirements for maintaining the privacy and security of protected health information.

Within the facility you must determine if components of your clinical record that are entered into a computer system, such as the MDS or care plan, will be printed and placed in the paper record or only be maintained electronically.  Either method is acceptable as long as it is in accordance with federal and state laws and regulations, and is consistent with facility policy (see CMS Survey & Certification Memo S&C-04-46 of September 9, 2004). 

It is helpful to establish a grid or matrix that identifies all components of the clinical record and whether, for purposes of the legal health record, that component is maintained in electronic or paper format.  Such a grid can be useful in ensuring all document types are addressed in planning the transition from hybrid to fully electronic health records. Including the date the information was converted to an electronic format is advantageous as it identifies the specific timeline of the conversion, particularly when it is a staggered conversion process. In addition, the grid can serve as a tool for communicating the paper or electronic status of document types to staff and, therefore, ongoing maintenance of the grid is important. 

Recommended content for a facility legal health record grid includes:

  • type and name of the document
  • media source considered as the legal health record (i.e. paper or electronic)

  • software application used to create and maintain the document

  • start date for electronic storage of the document

  • last date for printing document for inclusion in paper record

An abbreviated sample of a legal health record grid is found below in Table 1. 

The AHIMA Practice Brief Series “The Complete Medical Record in a Hybrid EHR Environment” (2003) presents a comprehensive review of issues related to a hybrid record system.  The series addresses:

  • Managing the Transition (Part I)
  • Managing Access and Disclosure (Part II)

  • Authorship of and Printing the Health Record (Part III)

  • Legal Source Legend (Appendix)

Review of this Practice Brief series is strongly encouraged.

TABLE 1:    LEGAL SOURCE LEGEND FOR HYBRID HEALTH RECORD

Report/Document Types

Media Type for Legal Record: (P)aper/ (E)lectronic

Software Application Source for Electronic Document

Start Date for Electronic Storage of Document

Last Date for Routine Printing of Document

IDENTIFICATION & ADMISSION DOCUMENTATION

Admission Record/Facesheet

P & E

Specify Application

1/1/2005

 

Pre-admission Screening (PASARR)

P

Admission Agreement

P

CLINICAL ASSESSMENTS

Nursing Admission Assessment

E

Specify Application

2/1/2005

4/1/2005

Fall Assessment

E

Specify Application

2/1/2005

4/1/2005

MINIMUM DATA SET AND CARE PLAN

MDS

E

Specify Application

1/1/2005

3/1/2005

Care Plan

P

Care Plan Signature Record

P

PHYSICIAN ORDERS

Monthly Recap

P

Telephone Orders

P

The following practice guidelines establish a baseline for the systems that should be in place for maintaining the clinical record in both paper and electronic formats.

Maintaining a Unit Record

A unit record and unit numbering system is recommended for long term care facilities. With a unit record, the patient is assigned a medical record number on the first admission to the facility.  This number is retained for each subsequent admission/readmission, and is used for both paper and electronic portions of the record. Though there may be multiple volumes, folders and formats, the patient’s entire medical record is filed as a unit under one number. (Health Information Management, Huffman)

In long term care, the record(s) from previous admissions may be brought forward and filed in the same area as the current admission, if space allows. Bringing previous records forward provides the most comprehensive picture of the resident’s medical history and therapy. The previous records should be readily accessible to staff for use in the assessment and care planning process.  

When a resident is readmitted, all records from previous admissions may be pulled forward and maintained in the overflow files, again, if space allows.  Records from previous admissions may be separated from other discharged/closed records to prevent the inadvertent destruction of the record(s) prior to the required medical records retention period (see "Practice Guidelines for LTC Health Information and Record Systems: Retention" for discussion of retention guidelines).  The medical records from previous stays remain in their original file folder and are retained, chronologically, with other records for residents currently in the facility. The records from one discharge to another are not combined into one folder.

If the previous records cannot be brought forward and kept in the same area as the current record, the facility may have a process in place to ensure that previous records are not inadvertently destroyed prior to the required retention period for the record. It is good medical record practice, and benficial from a clinical perspective, to retain those records from the resident's previous stays, however, facility policy and financial or space requirements may not allow for this practice.

Some software products have been setup to assign a new number with each readmission to the facility.  In this situation, the previous records should be brought forward and filed under the latest number assigned to the resident.  The software vendor should be queried as to whether there could be a mechanism by which the previous admission could be identified, possibly through the addition of a character to the resident's identifier.

If information from a prior admission(s) is in an electronic format, the information must be viewable upon readmission and staff need to be made aware of its availability.

Assigning a Medical Record Number

HIM STANDARD:

The healthcare organization has a policy that requires a separate, unique health record for each resident.

Each resident admitted to the long term care facility should be assigned a unique medical record number. The following are general rules to follow when assigning medical record numbers:

  1. Assign a medical record number only when a resident is admitted. This will prevent numbers from being assigned when the resident is not actually admitted to the facility.
  2. If a resident was assigned a number, but was not admitted, make a notation in the admission/discharge register (see "Indexes and Registries: Admission/Discharge Register") that the resident was not admitted.  Do not reuse the number.

  3. Assign numbers chronologically. Each new admission is assigned the next sequential number.

    • Always verify in the master patient index (see Indexes and Registries) that the resident has not been in the facility previously.

    • If a resident has multiple admissions, the facility can assign a modifier to the medical record number to designate each admission, such as 1234-a, 1234-b or 1234-1, 1234-2.   

  4. When a resident is re-admitted, the original medical record number is used.

    • No additional entry is needed in the medical record number log, but the readmission is noted on the master patient index card.

Special considerations for healthcare campuses or continuums of care (i.e. facilities with nursing home and assisted living components, continuing care retirement communities, etc.):

  •  How the facility uses the medical record number is a key consideration when assigning numbers in a facility with different care settings.  Is the medical record number used for filing sequence (i.e. patient records are filed in numerical sequence based on the medical record number) or is the medical record number only used for purposes of patient identification?
  • If the medical record number is used for filing sequence, a separate number should be assigned to each of the different care settings, such as a separate medical record number for the SNF stay and a separate medical record number for the Assisted Living stay.  On readmission to either the SNF or AL, the number originally assigned in that setting would be used again.
  • If the medical record number is used only for patient identification, the facility may want to consider assigning a single medical record number to be used for records created in any of the different care settings, issuing in essence a “campus” number.  A modifier may be used to indicate the specific care setting to which the patient is being admitted.  For example, if the resident is being admitted to the Assisted Living portion of the facility, the suffix “AL” may be added to the number to designate the Assisted Living stay, creating the number 1234(AL).

Special considerations for multi-facility organizations:

Accurate identification of customers being served, the frequency of customer use of specific services, and the profitability of such services are strong motivators for corporations to consider adoption of an enterprise identifier.  An enterprise identifier is the primary identifier used by the corporation to identify the resident across facilities in the enterprise.  It is used at the corporate level to link and identify residents, while the medical record number is still used for identification at the facility level.

General:

Electronic systems should provide fields for medical record numbers that are of adequate length and type (i.e. alphanumeric vs numeric only) to support the numbering convention of the facility.  If the system cannot support existing numbering conventions and a new numbering system is initiated, the facility will have to cross-reference the new number on the master patient index and the resident’s medical record folders.

Electronic systems should also have the ability to automatically assign sequential numbers for new admissions and search for prior admissions of the resident to the facility.  It is important to remember that the system can only search for prior admissions based on the data available.  It may still be necessary to search the manual patient master index for prior admission status if the system data base is of a limited timeframe.

Finally, electronic systems should support collection of demographic information and pre-admission assessments prior to resident admission to the facility.  Such pre-admission information should be distinct from “resident” information and would not be associated with a medical record number until such time as the resident is admitted to the facility.

Enterprise Identifiers:

Use of enterprise identifiers requires all facilities to search the corporate database for previous admissions to avoid assigning more that one number to a resident previously admitted within the organization.  Effective use of enterprise identifiers hinges on accurate identification of the resident to avoid duplicate, overlap, or overlay entries in the corporate database.  The matching algorithm used to determine if the resident exists in the corporate database is critical to avoiding errors in assignment of identifiers.  Three types of algorithms are currently available: deterministic, rules-based, and probabilistic. These concepts are discussed in detail in the AHIMA Practice Brief "Building an Enterprise Master Person Index from January 2004."

Maintaining Records in a Continuum of Care

For healthcare campuses or continuums it is recommended that separate records are maintained for each of the different care settings. For example, a separate record is maintained for assisted living, one for the NF/SNF, another for home care, a record for outpatients, etc.  Creation of a new record is not recommended when a resident changes levels of care within the nursing home, i.e. moves from SNF to NF.

When transferring between care settings (i.e. assisted living to SNF), it is recommended that an interdisciplinary transfer form or discharge instructions be completed to ensure continuity of care. Include copies of relevant documentation to facilitate the assessment and care planning process.

Health information staff should be responsible for record management.  This includes creation, maintenance, storage, retention, and destruction of the medical records maintained by the campus.  The assignment of responsibility helps to ensure that the medical records for each of the care settings are maintained in an organized and systematic filing and retrieval system.

To assist with tracking medical record numbers/campus numbers, admissions, discharges and transfers,  there should be a campus-wide master patient index or some other mechanism to link all paper, electronic and hybrid records to the resident. 

Electronic systems should have the ability to maintain a campus-wide patient master index.

Defining What is Part of the Medical Record

The medical record in a long term care facility reflects the multi-disciplinary approach to assessment, care planning and care delivery. The medical record includes, but is not limited to, the following types of information: resident identification, admission/readmission documentation, advance directives and consents, history and physical exams and other related hospital records, assessments, MDS, care plan, physicians orders, physician and professional consult progress notes, nursing documentation/progress notes, medication and treatment records, reports from lab, x-rays and other diagnostic tests, rehabilitation and restorative therapy records, social service documentation, activity documentation, nutrition services documentation, and other miscellaneous records including correspondence and administrative documents.

Facility policy should specifically outline in the format of a chart order the exact documents and records that will be considered part of the medical record.

If portions of the record will be retained in an electronic medical record system, policies should differentiate between those records that will be paper-based and those that are electronic. (see overview above)

Maintenance of the Medical Record

It is critical that both the active record and the overflow records are maintained in a systematically organized fashion. This means that all records have an established chart order or order of filing that is followed. All records (records on the nursing station, overflow records, and discharge records) should be readily accessible, maintained in an organized chart order, filed in an easily retrievable manner, and maintained in folders or chart holders sufficient in size for the volume of the record. The chart holders and folders should be kept neat, clean and orderly. Products are available for cleaning/disinfecting the chart holders (binders).  Cleaning is recommended periodically during the stay and upon discharge.

It is recommended that a chart order or order of filing with thinning guidelines be kept in the record and at the nursing station to direct staff to the proper location of forms.

In hybrid or electronic record environments, procedures must be clearly defined regarding how staff are to handle interruptions in the ability to electronically chart due to situations such as power failure or system failure.  Issues to address include:

  • Is manual charting created during the time the system is down
  • If manual charting is created, is it maintained as part of the legal health record
  • Is manual charting replicated as a “copy” in the electronic documentation once the system is accessible
  • What type of notation is made in the electronic documentation to identify any manual charting created during the system down time.

Identification (Name and Number) on pages of the Medical Record

From a legal perspective, each page or individual documents (i.e. shingled telephone order) in the medical record should contain resident identification information. At a minimum, both the resident name and medical record number should be on each form. If labels/label paper is used, resident identification information must be included on the label. The resident name and number should be placed on both sides of a two-sided form/page because records are frequently copied.  Identification information appearing on both sides of a form helps to ensure that the copy is not lost or misplaced.  If the back of the form is blank, no identification information is required on the blank side.  There should not be documentation on the back of a one-sided form.  If, for any reason, documentation is placed on the back of a one-sided form, a label or identifying information must be added and any blank space on the form lined or X’d out to prevent further documentation that may be out of sequence.

Resident identification information can be noted on forms by methods such as writing on the page in permanent ink, stamping by an addressograph, or affixing a printed or manually completed label. Regardless of the method used, identification information should not obscure any content on the form. Resident specific documents printed from a computer system to be filed in the medical record, such as physician orders, care plans, etc.,  should include resident identification information on each page.

In electronic or hybrid environments, it is important that core resident identification information appear on each screen view of the resident’s clinical information as well as on each page of hard copy output.  Again, at a minimum, both the resident name and medical record number should be present.

Common Forms and Thinning Guidelines

HIM STANDARD:

The healthcare organization has a policy that establishes a uniform chart order for health records.

This section outlines common forms found in a long term care record and provides guidelines for thinning the record contents.  While form titles listed and the location of the forms in the record may differ from facility practice.

Thinning the medical record is a process of removing documents older than a certain date and moving them into a secondary record known as the overflow record.  The establishment of thinning guidelines is a standard of practice for the long term care profession. Federal regulations at 42 C.F.R. § 483.75 (l)(5) require that clinical records include (1) sufficient information to identify the resident; (2) a record of the resident’s assessment; (3) the plan of care and services provided; (4) the results of any pre-admission screening conducted by the State; and (5) progress notes. Some states may have specific regulations that address what can be thinned from the active record. Check licensure rules to determine if state law delineates a specific thinning guideline.

The goal of the thinning guideline is to retain documentation in the resident’s chart that reflects the current plan of care and services provided, as well as maintaining a record of manageable size for use by the care providers. Unless required by state regulations, it is not necessary to keep the original assessment or progress notes in the record. Recommended guidelines for thinning call for retaining the two most recent assessments in the active record.  The overflow record should be appropriately secured and easily accessible to clinical staff for review of any admission or other type of documentation.

Section 4.3.6 presents information on considerations related to leaving records “open” versus “closing” records when a resident has been temporarily discharged (such as for hospitalization) and return to the facility is anticipated.  If a facility has established a policy to leave the record “open” during temporary discharge, then they will also need to identify practices for thinning of documents such as old admission forms or advance directives from the record which is being continued following readmission.

In a hybrid record, thinning will only apply to documents identified for inclusion in the paper medical record.  Electronically stored forms, documents, and information must be retained and accessible as needed for providing care, quality review, survey, etc.   The facility needs to have a thorough understanding of any processes for automatically archiving data that have been built into their clinical information system, as well as processes for retrieving the archival information.  All components of an electronic record need to reside on the system in accordance with facility retention guidelines.

Clinical information in the electronic system may not be presented in the same format as the hard copy record.  In an electronic record, data elements will be sorted and pulled to populate a variety of views, forms or reports.  It will become more important to identify data elements that are common to a variety of reports.  Duplicative entry of data elements should be eliminated as the database or data dictionary is built and accessible.

Integrating Hospital Documents into the Long Term Care Record

Records from a hospital or other healthcare provider (i.e. another LTC facility) that are sent with a resident to provide information for continued care and treatment should be retained by the facility. It is recommended that pertinent information such as the history and physical, discharge summary, and transfer form be kept in the active medical record. All other documents sent (copies of progress notes, labs, consults, etc.) should be kept in the active record for  1 month to provide information when establishing the current plan of care and treatment and then thinned and retained in the resident’s overflow record. The records provided on admission, readmission, or return from the hospital are part of the facility record. See "Redisclosure Upon Transfer to Another Healthcare Facility"  for guidance on how to handle release of information or redisclosure of hospital and other healthcare provider documents.

While the federal conditions of participation do not require LTC facilities to obtain a resident History & Physical (see Documentation in the Long-Term Care Record: History and Physical), many times state licensure rules or facility policy impose this requirement.  A copy of the history and physical from the hospital is commonly accepted as the history and physical on admission to a LTC facility.  If the hospital physician is also the attending physician, the hospital H&P must be signed and dated by that physician.  When the hospital physician is not the attending physician, the hospital H&P must be reviewed by the attending physician, changes in condition, if any, noted and the attending physician must sign and date the H&P.  When necessary, physicians are expected to update the hospital H&P, hospital discharge summary or to write a progress note that documents the resident’s condition at the time of admission to the facility.  “Electronic” H&Ps that have been faxed or e-mailed from the hospital and printed by the facility would require signature as outlined above.

As with paper copies of hospital documents, electronic documents provided upon transfer from the hospital will need to be integrated into the resident’s record.  If the legal health record is paper based, the electronic documents should be printed and filed in the record as discussed above.  If the legal health record is in electronic format, the electronic information from the hospital should be integrated in a manner such that the source is clearly identified, but the information is retrieved, archived, and destroyed as part of the resident record.

Thinning the Medical Record

Each facility should develop a schedule for thinning the medical records. It is generally recommended that records are thinned quarterly and as needed. Using the MDS/care conference schedule, and thinning after the care conference, can provide calendar for thinning Only documents that are signed and complete are thinned.

Once the record has been thinned a notation may be made in the record. For example, a label can be placed in the inside cover of the chart that states the date the record was thinned. The records thinned from the chart should be filed in the overflow record immediately to assure that resident records are always accessible and easily retrievable. 

By listing a form in the following chart order, we are identifying documents commonly found in the medical record. This should not be interpreted as a recommendation or requirement that the form be a mandatory part of the long term care record. See "Documentation in the Long-Term Care Record" for required types and content of documentation and the associated regulatory reference.

COMMON CHART FORM*

RECOMMENDED THINNING GUIDELINE

(State Regulations May Be More Stringent And Supersede These Guidelines)**

Identification and Admission Documentation

  • Admission Record/Facesheet
  • Pre-admission Screening (PASARR)
  • Preadmission Assessment/Intake
  • Admission Agreement (new agreement not required on readmission after temporary discharge with return anticipated)
  • Admission Consent



Current Facesheet

Most Current

3 months after admission

Financial/Administrative file



Permanent

History and Physical and Hospital Records

  • H&P
  • Hospital Discharge Summary
  • Hospital Transfer Form
  • Other Hospital Records  (All hospital records received should be retained as part of the facility clinical record)
  • Immunization Records


Most Current

Most Current

Last Hospital Stay

Retain pertinent records for 1 month after hospitalization & then thin

Permanent

Advance Directives/Legal Documents

  • CPR Directive
  • DNR Order from physician
  • Resident Self Determination Act Acknowledgement.
  • Living will
  • Advance Directive
  • Durable Power of Attorney
  • Guardianship/Conservator
  • Legal incapacitation
  • Consents, Acknowledgements (For example, Physical Restraints Consent, Admission Consents, Consent to Treat, Consent to Photograph, MDS Consent, MDS Acknowledgement, Release of Information Consent, Release of Responsibility/Leave of Absence)


Most Current

Most Current

Most Current

Most Current

Most Current

Most Current

Most Current

Most Current

Most Current

Clinical Assessments (At a minimum, retain most recent assessment plus one previous)

Nursing Assessment

Wound and Skin Assessments

Fall Assessment

Bowel and Bladder Assessment

Pain Assessment

Mini-Mental/Cognitive Exam

Restraint Assessment




6 months to 1 year

6 months to 1 year

6 months to 1 year

6 months to 1 year

6 months to 1 year

6 months to 1 year

6 months to 1 year

Minimum Data Set and Care Plan

MDS

Care plan

Specialty Care Plans ie: hospice/dialysis

Care Plan Signature Records (if used)

Care plan recap (if used)



15 months readily available

Current care plan

Current plan

Current plan

Current plan

Physicians Orders

Monthly Recaps or Renewals

Telephone Orders

Interim orders

Protocols or Standing Order Policies (if used)

Fax Orders



3 months

3 months

3 months

Current

3 months

Physician and Professional Progress Notes/Consults

Physician Progress Notes

Cumulative Problem/Diagnosis List

Annual Exams

Other specialists/consultation

Dental Progress Notes/Exams

Podiatry Progress Notes/Exams

Psychological Evaluation




1 year

Most recent

Most recent

1 year

1 year

1 year

Current

Nursing Notes/Interdisciplinary Notes

Nursing Notes or

Interdisciplinary Notes

Nursing Summary Forms/Flowsheets



3 months

6 months

3 months

Medication, Treatment and Other Flowsheets

Monthly Medication and Treatment Records

Vitals Sign Record

Weights Record

Intake and Output Records

Behavior Monitoring Records

Other Flow Sheets (Diabetic site rotation, etc)

Pharmacist/Drug Reviews Recommendations




3 months

1 year

1 year

3 months

3 months

3 months

1 year

Lab, X Rays, and Special Reports

Lab Reports (frequently ordered)

Annual or interim Lab Reports

X-Ray Reports

Special Diagnostic Tests



3 months

1 year

1 year

1 year

Rehabilitative Therapy (PT, OT, SLP)

Therapy Evaluation

Therapy Certification/Recertification

Progress Notes

Discharge Summary

Therapy Screen

*Once therapy is discontinued thin therapy information for that discipline except the evaluation and discharge summary.



Most Recent

3 months

3 months

Most Recent

Most Recent

Rehab Nursing

Rehab Screen

Rehab Nursing Assessment

Progress Notes/Treatment Records



Most Recent

Most Recent

3 months

Activities (Therapeutic Recreation)

Progress notes

Assessments



6 months to 1 year

Most Recent

Dietary (Nutrition Services)

Progress notes

Assessments



6 months to 1 year

Most Recent

Social Service

History

Progress notes

Assessments



Permanent

6 months to 1 year

Most Recent

HIPAA Documents

HIPAA Requests

Accounting of Disclosures (if applicable)

Requests for Amendment

Requests for Alternative Communication

Requests for Restriction of Access to PHI

HIPAA Complaints

Request to Opt Out of NPP practices

Authorization to Use and/or Disclose Protected Health Information



Most Current

Most Current

Most Current

Most Current

Most Current

Most Current

Most Current

Most Current

Miscellaneous/Legal

Clothing list or Inventory List (If required)



Most Current

*Common Chart Forms – The chart forms and location are not meant to represent a recommended chart order or forms. Chart order and the types of forms used are facility-specific. The forms named represent common types of documentation found in a long term care record. 

** Thinning Guidelines – These guidelines are recommendations and provide a baseline. Each facility should adapt and develop thinning guidelines that meet the needs of their resident population and staff needs.

Maintaining the Overflow Record of Thinned Documents

The overflow record is considered part of the resident’s active medical record. The overflow records which contain the documentation thinned from the chart must be systematically organized (a chart order should be established) and readily accessible. Because it is not always possible to keep all documentation in the chart holder at the nursing station, the thinned information is generally kept in the HIM department.

Standards for maintaining the overflow medical record:

SYSTEMATICALLY ORGANIZED:

  • For ease in locating documents a chart order should be developed for overflow records. It is recommended that the overflow chart order be the same as the discharge chart order to facilitate quick assembly upon discharge. All like forms should be filed together (i.e. all nurses notes together in date order). Use index tabs if desired to indicate the sections of the chart (index tabs from an office supply company work well in thinned charts). Tabs will make retrieval and filing of documents easier.
  • Contents of records should be maintained in date order. Facility policies should define if forms will be filed in chronological or reverse chronological order. Filing in chronological order has been considered the gold standard, but reverse chronological order has now become more widely used and can save a considerable amount of time by eliminating the need to reverse the order of the documents when thinning or closing the record.  If reverse chronological order is adopted, the chart order remains the same for active, thinned and discharged/closed records.  Either method is acceptable but the facility must define in a policy which of the methods will be used and consistently apply that method.
  • Overflow records should be filed alphabetically by resident last name.

READILY ACCESSIBLE:

  • Overflow records should be filed in a location that is secure and readily accessible.
  • When overflow records are removed a chart locator or tracking system must be used to identify the individual removing the chart, the date, and the location.

Maintaining a "Soft Chart" or "Shadow Record" and Other Types of Records

Soft charts are resident-specific records maintained by a discipline that containextra notes, observations and copies of documentation kept in the medical record. This record is not usually integrated with the resident’s legal medical record. The soft chart is often a working duplicate of the medical record but may also contain information that should be in the legal medical record, but is documented in the soft record and never transferred to the legal record.

Soft charts are discouraged. The facility is put at legal risk because a soft record is discoverable in a legal process and could contain contradictory or damaging information. There is potentially a loss of critical information  when information is documented in the soft record and never transferred to the legal medical record.

If facility administration approves the use of soft charts, policies should be developed to manage the records with the same structure and organization as the resident’s legal medical record. The following systems should be developed for each type of soft chart:

  • Implement systems to ensure that the records are physically secure such as retaining information in locked file cabinets with access by limited staff.
  • Develop policies to address the confidentiality of information and documents contained in the record.
  • Identify these records on the retention and destruction schedules.

Social Service and Financial Files:

Separate social service and financial files are commonly maintained by long term care facilities. Both of these types of records are acceptable. They contain information that is highly sensitive and often not related to resident care. If your facility uses separate files for these two areas, develop policies to define what information is retained in each type of record. There is a risk with a social service file that information which should be documented in the medical record is kept only in the social service record and not accessible to other care providers. Policies should also define security, confidentiality, retention and destruction.

Communication Records/Shift Worksheets:

Communication and Shift Records are a common form of communication between nursing staff working on different shifts. They usually contain multiple residents on one page and are not considered a formal part of the medical record. These records are acceptable but standards should be in place to assure that the medical record also reflects the resident’s condition, nursing observations, and assessment that are often found in the communication records. It is critical that the medical record contain the same information as the worksheets on condition, observation and assessments.

Facility policy should establish retention and destruction procedures. Determine where the reports will be stored, how they will be collected, how long they will be retained, and when they will be destroyed. In absence of a state law, it is recommended that shift reports be retained for 30 days and then destroyed.

Outpatient Records and Records Maintained by Vendors:

When vendors such as a therapy provider is contracted with a facility, it is acceptable for a the company to maintain their own medical record. The facility must ensure that the vendor providing outpatient services through the facility has appropriate policies in place to deal with security, confidentiality, retention and destruction.

If facility staff is providing outpatient services, the facility must develop and manage the record systems and procedures to assure security, confidentiality, retention and destruction. If the facility employs the therapists, it is not recommended that they have a separate therapy chart (soft chart). All documentation should be maintained in the medical record.

Communication Records/Shift Worksheets

In a hybrid record, consideration should be given to which staff members have a need for access to different areas within the electronic record. If identified in the development stages, it is easier to identify safeguards that can be built into the electronic portions of the record to deny access based on assigned responsibilities. Access levels can be assigned based on these responsibilities. 

In preparing for the electronic record, team members should also consider the possibility of built in “alerts” and “task lists” that can be automatically generated to specific employees.  This will enable information to be shared in real time.  When possible, entry of information into a specific area should generate or enable the author to generate information to others affected by the action.  For example, when a new admission is received, an alert should go to dietary so that they can prepare for the resident’s integration into the nutritional system and plan to include the resident in the meals going forward. 

Outpatient Records and Records Maintained by Vendors 

In a hybrid record, electronic records maintained by therapy providers must be addressed in facility policies and procedures and the procedures clearly defined for use of electronic signatures.

In the electronic environment, data entry could be mapped to provide pertinent information to all appropriate areas within the electronic record. 

Forms Control Processes

HIM STANDARD:

• A procedure has been established to address issues related to the establishment and completion of all health record forms and data entry screens.

A process should be in place to review and approve new or revised forms. There should be a formal process such as a forms committee to carry out the following functions:

  • Title, index, and maintain a master of each form.
  • Review and approve new forms. New forms should be reviewed for:
    • Content,
    • Potential duplication of information already being captured in another area or form, and
    • Inclusion of basic identification information on all pages of form: Title of form, resident name, medical record number, page numbers ( page x of y) if applicable, form control number if applicable, and revision date.
    • Format appropriate for type of chart holder used (i.e. when form is placed in chart holder, information is not presented upside down)
  • Review and approve revisions to forms.
  • Identify forms which should be deleted or inactivated and ensure that the form is no longer available for use.

In the hybrid environment, the forms committee will still function in the same manner as mentioned in the paper record, but it will also begin to take on the responsibility of guiding the process of building and maintaining the data dictionary to eliminate duplication of entries and appropriate mapping to documents and forms.  As facilities move closer to a totally electronic record, the forms committee will transition into this new responsibility.

Note: Also take responsibility for screen design, customized views, report output, understand user interaction with the system


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