Health Records in the Acute Care Setting

Khristina Kisner
HCMT1020C 002

Fall 2015

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Health Records in the Acute Care Setting
What is Acute Care?
Acute healthcare includes services whose purpose is to, include all
promotive, preventive, curative, rehabilitative or palliative actions, whether
oriented towards individuals or populations, whose primary purpose is to
improve health and whose effectiveness largely depends on time-sensitive
and, frequently, rapid intervention, (WHO, 2013). As the population in the
United States continues to age, the demand for acute care increases. From
acute curative services responding to life-threatening emergencies, or acute
exacerbation of chronic illnesses and routine health problems that require
prompt action, acute care is a widely used care setting (WHO, 2013).
Acute care includes a wide range of healthcare providers from
emergency medicine, trauma care, pre-hospital emergency care, acute care
surgery, critical care, urgent care and short-term inpatient hospitalization
(WHO, 2013). Acute surgical needs, for example an acute appendicitis is one
type of care given in an acute care setting. Life-threatening health condition
treatment, from acute myocardial infarctions and acute cerebrovascular
accidents, to seeing a patient to evaluate why they have abdominal pain,
these are just a few examples of acute care given to patients (WHO, 2013).
Patient care documented in the Health Record
Health records and clinical documentation are important in the delivery
of direct patient care and the operation of individual healthcare organizations
(Clark, 2004). It is important for patient care to be accurately documented in

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a timely manner in the acute care patient record, as well as in any other
healthcare setting (Clark, 2004). The format of the health record, whether it
be paper-based, hybrid or an electronic-health record, doesnt change the
fact that every aspect of patient care must be fully documented to insure
high-quality patient care and proper facility reimbursement. The saying goes,
if it wasnt documented, it wasnt done. A third-party payer wont pay for
an x-ray if there isnt proper documentation that it was performed. Why
should someone pay for a service that wasnt performed? This stresses the
importance of the health record.
The format of an acute care facilitys health record can vary from
locale to scope of practice (Fahrenholz & Russo, p. 31, 2013). UC Hospital in
Cincinnati will not have the same format for their legal health record as a
private hospital in Seattle. Each organization will take a different approach
when developing their version of the legal acute care health record. When
their definition of the legal acute care record is defined, they must be certain
to follow documentation requirements for the acute care record. The Joint
Commission, the federal Conditions of Participation, state licensure
regulations, payer regulations and professional practice standards must all
be taken in account when documenting acute patient care (Smith, 2001).
The main purpose of the acute care patient record is for documenting care of
the patient, but is also used for collecting, storing and processing patient
information (Smith, 2001).

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There are basic components found in the acute care health record
whether it is paper-based, hybrid or electronic. A patients demographic
information which consists of name, date of birth and other personal
information is part of the registration information part of the acute care
record (Sayles, p. 77, 2014). Where the patients physician documents the
patients current and past health status is the medical history and is also
included. A physical examination contains the providers findings after the
patient has been examined and also is found in the acute care record
(Sayles, p. 77, 2014). Two other critical parts of the acute care record are the
clinical observations and physicians orders. Clinical observations are a
chronological summary of the patients illness and treatment provided to the
individual patient by each healthcare provider. The instructions from the
patients physician to other healthcare providers are the physicians orders.
These orders include orders for medications, diagnostic and therapeutic
procedures (Sayles, p. 77, 2014). If the patient has tests or procedures done,
these are the reports of diagnostic and therapeutic procedures. The names of
clinicians and a description of the procedures are found here as are the
findings of x-rays, mammograms, lab tests or other diagnostic procedures
(Sayles, p. 77, 2014). The attending physician in charge of the acute care
patient will sometimes ask another physician for a consultation or second
opinion when trying to determine a definitive diagnosis. This opinion from
another physician is documented in the consultation reports part of the acute
care record. Once the patient has been treated and is ready to be released, a

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discharge summary is where the information is summarized detailing the
patients acute care treatment (Sayles, p. 77, 2014). The patient is given
information from their physician in the form of patient instructions, the
follow-up information given to the patient or their caregiver. It instructs the
patient to follow-up with their family physician, post-discharge treatment
instructions and any signs and symptoms to look for that indicate their
condition is worsening. A patient must consent to treatment, this consent is
documented in the consents, authorizations and acknowledgements part of
the acute care record. The patients agreement to undergo treatment,
permission to release confidential information or recognition that this
information has been received will all be included in this part of the acute
care record (Sayles, p. 77, 2014).
Documentation Requirements for Acute Care
There are many documentation requirements for acute care health
records. Two organizations that have requirements affecting acute care are
The Joint Commission (JC) and The Centers for Medicare and Medicaid
Services (CMS) Conditions of Participation. One documentation requirement
from both CMS and JC is the acute care record must contain sufficient
information to identify the patient, support the diagnosis, justify the
treatment, document the course and results and promote continuity of care
among healthcare providers (Smith, 2001). CMS requires that acute care
records must document the discharge summary, which should include the
outcome of hospitalization, disposition of the patients case and provisions

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for follow-up care. Along with this is the final diagnosis must also be included
with completion of the medical records within 30 days of discharge (Smith,
2001). The JC requires the acute care record must contain documentation
that the patients history and physical examination was completed within 24
hours of admission (Smith, 2001). If the history and physical has been
performed within 30 days before admission, a legible copy of the exam may
be included in the patients acute care record. If a patient is scheduled for
surgery, any indicated diagnostic tests, a preoperative diagnosis and medical
history must be completed and recorded in the patients medical record
(Smith, 2001). Many other requirements exist for what is to be documented
in the acute care health record.
The acute care health record is an important legal document used to
document patient care. When properly documented, patient care is highquality and provider reimbursement is provided for services rendered.

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References
Clark, J.S. (2004). Documentation for acute care. Retrieved from
library.ahima.org
Fahrenholz, C.G., Russo, R. (2013). Documentation for health records.
Chicago, IL: American
Health Information Management Association.
Hirshon, J.M., Risko, N., Calvello, E.J.B., Stewart de Ramirez, S., Mayur, N.,
Theodosis, C., &
ONeill, J. (2013). Health systems and services: the role of acute care.
Bulletin of the
World Health Organization 91: 386-388.
Sayles, N.B. (2014). Health information management technology: an applied
approach.
Chicago, IL: American Health Information Management Association.
Smith, C.M. (2001). Documentation requirements for the acute care inpatient
record (AHIMA
practice brief). Journal of AHIMA, 72, 3: 56A-G.