Determine compliance of health record content

HITT Lab APA Format

AHIMA Competency l.4:  Determine compliance of health record content within the health organization.

(Bloom level: 5)

After reading Chapters 3, 4, you know that incomplete records slow down the process for insurance payments and hospital reimbursements.  Below, identify a complete health record by ensuring its contents support documentation requirements of a health record.

 As an HIM chart analyst, you are reviewing the chart of a patient who was admitted on 2/17 with gallstone pancreatitis. She arrived through the emergency department on Wednesday afternoon in severe abdominal pain. After lab work was performed showing an increased lipase level, she was admitted. Her family physician evaluated her the next morning and ordered an ultrasound and repeat lab work. The ultrasound showed gallstones, and the lab work indicated the lipase was coming down. He consulted a general surgeon, who evaluated the patient and agreed to perform cholecystectomy on Friday if the lipase level returned to near normal levels. Surgery was then performed on Friday morning, and after an uneventful night, the patient was discharged home on Saturday morning. On 2/25, you have the following documentation available in the EHR:

H&P                                                                       dictated 2/18        authenticated 2/18 Consultation report                                             dictated 2/18         authenticated 2/23 Immediate post-op note                                      written 2/19          authenticated 2/19 Operative report                                                  dictated 2/20         authenticated 2/21 Discharge summary                                             dictated 2/22         authenticated Lab work from all dates of stay Nursing notes from all dates of stay Anesthesia documentation from surgery Physician orders from all dates of stay all signed Progress notes—all signed Medication list—signed

At your facility, the guidelines for record completion are as follows: • ED reports within 24 hours • H&Ps within 24 hours of admission • Operative reports within 24 hours of the procedure with a post-op note present immediately after the procedure • Consultation reports within 48 hours • Discharge summary within 14 days

Questions:

1. Determine whether the record is complete or not and provide support for your answer. 2. When a record is deemed incomplete, what steps must be taken to get the record completed?

Explanation & Answer

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